Failure to Notify Practitioners of Missed Medications and Lack of Treatment Orders
Penalty
Summary
The facility failed to ensure that practitioners were notified when medications were missed due to unavailability for four residents. For one resident with type II diabetes mellitus and central pain syndrome, Gabapentin was not administered for two consecutive days, totaling six missed doses, without evidence that the practitioner was notified. Another resident receiving hospice care for dementia and anxiety did not receive multiple doses of Lorazepam as ordered, and there was no documentation that the physician was informed of these missed doses. A third resident with congestive heart failure missed a dose of Torsemide, and a fourth resident with congestive heart failure and hypothyroidism missed two doses of levothyroxine, with no evidence of practitioner notification in either case. Additionally, the facility did not provide treatment in accordance with professional standards of practice and physician orders for one resident. This resident, diagnosed with Charcot's joint and gout, was observed wearing a right lower extremity splint. However, there were no physician orders, documentation, or care plan interventions related to the splint at the time of observation. The absence of orders and documentation for the splint was confirmed during interviews and record reviews. These deficiencies were identified through policy review, clinical record review, observations, and interviews with residents and staff. The facility's own policy required staff to notify the pharmacy and the practitioner if a medication was unavailable and a dose would be missed, but this was not followed in the cases reviewed. The lack of documentation and practitioner notification for missed medications and the absence of orders and care planning for the splint constituted failures to provide care and treatment according to orders, resident preferences, and professional standards.