Failure to Ensure Provider Review of Care Plan and Medication Orders
Penalty
Summary
The facility failed to ensure that the resident’s care plan was thoroughly reviewed and followed by all providers during and after a change in primary care providers, resulting in a missed neurology follow-up and inappropriate discontinuation of seizure medication. A resident with a complex medical history, including chronic obstructive pulmonary disease, ischemic heart disease, history of stroke, and a recent diagnosis of seizure activity, was discharged from the hospital with instructions to continue Keppra and to follow up with neurology. The hospital discharge summary specifically recommended an outpatient neurology appointment to determine the long-term plan for seizure management, and the medication Keppra was ordered to continue upon admission to the facility. Despite these clear instructions, no neurology consult was ordered or initiated after the resident’s admission. Multiple providers, including nurse practitioners and physicians, saw the resident during routine and regulatory visits but failed to recognize or act on the need for a neurology follow-up. Progress notes from these visits did not mention the missed neurology appointment, and providers reported in interviews that they were unaware of the hospital’s recommendation. Additionally, there was a change in the primary provider team, and the new team did not identify the need for neurology follow-up or review the full plan of care as outlined in the hospital discharge summary. On a later date, a verbal order to discontinue Keppra was entered into the resident’s record without clear documentation of who gave the order or the clinical reasoning behind it. The physician’s electronic signature appeared on the order, but both the nurse practitioner and physician interviewed did not recall authorizing the discontinuation. The resident’s medication administration record showed that Keppra was stopped, and subsequent physician progress notes incorrectly listed Keppra as an active medication. The lack of coordination and communication among providers led to the resident experiencing a seizure and requiring hospitalization in the intensive care unit.