Failure to Timely Notify Physician of Cardiologist's Medication Recommendation
Penalty
Summary
Nursing staff failed to notify the attending physician in a timely manner of a cardiologist's recommendation to reduce a resident's Carvedilol dosage from 25 mg to 6.25 mg twice daily. The resident, who had chronic diastolic congestive heart failure and chronic obstructive pulmonary disease with moderately impaired cognition, attended an outside cardiology appointment where the dose reduction was recommended due to junctional bradycardia. Upon return, the resident's family handed the cardiologist's report to a nurse and communicated the presence of recommendations. However, there was no documented evidence that the physician was notified of the cardiologist's recommendation as required by facility policy. As a result, the resident continued to receive the higher Carvedilol dose of 25 mg twice daily for several days following the cardiology appointment. The medication administration records confirmed the continued administration of the higher dose until the physician was finally notified and the order was changed to the recommended lower dose. Interviews with nursing staff and the physician confirmed that the standard procedure of reviewing recommendations, notifying the physician, and documenting the communication was not followed, and the physician was not made aware of the cardiologist's recommendations until several days later.