Failure to Notify Practitioner and Family of Repeated Medication Refusals
Penalty
Summary
The facility failed to notify the medical practitioner and family of a resident's repeated refusals to take prescribed medications. Record reviews showed that the resident, who was unable to complete a cognitive assessment, had multiple medications ordered for conditions including pain, heart health, hyperlipidemia, hypertension, depression, GERD, memory support, dementia, and constipation. The Medication Administration Record indicated that the resident refused several medications on numerous occasions throughout the month. Despite these repeated refusals, there was no documentation in the progress notes that the primary medical provider was notified of these events. An interview with the Director of Nursing confirmed that the practitioner was not informed of the resident's medication refusals, which was contrary to facility policy. The policy required documentation of the refusal, including notification of the healthcare practitioner within a timeframe determined by the resident's condition and the potential seriousness of the consequences. The lack of notification and documentation represented a failure to follow established procedures for managing medication refusals.