Failure to Notify Practitioners of Missed Medications and Non-Compliance with Care Orders
Penalty
Summary
The facility failed to notify practitioners regarding significant changes and issues affecting two residents. For one resident with severe cognitive impairment and multiple diagnoses including cancer, atrial fibrillation, and malnutrition, the facility did not administer a prescribed anticoagulant (Xarelto) for seven consecutive days. Despite the facility's policy requiring physician notification when medications are unavailable or missed, the resident's practitioner was not informed of the missed doses. Another resident, who had orders for fluid restriction, steroid eye drops post-cataract surgery, and thigh-high compression garments, experienced multiple lapses in care. The facility did not notify the physician when the resident repeatedly exceeded fluid intake limits, missed multiple doses of prescribed eye drops, and went without compression garments for over a month while waiting for a larger size. Although the physician was eventually notified of increased edema and the absence of compression garments, this notification was delayed, and there was no documented follow-up with the physician after the initial contact.