Failure to Document Medication Refusals and Notify Physician
Penalty
Summary
The facility failed to follow its policy and procedure for administering medications for one resident by not documenting multiple refusals of a prescribed medication and not notifying the resident's physician of these refusals. The resident, who had a history of chronic ulcerative recto sigmoiditis, malignant neoplasm of the sigmoid colon, and vascular dementia, was scheduled for a colonoscopy and had a physician's order to receive Golytely Oral Solution as preparation. The medication was to be administered in specific amounts at set intervals until the entire dose was consumed. On the day prior to the scheduled colonoscopy, the resident only consumed part of the prescribed Golytely solution and refused further doses a total of seven times. The licensed nurse on duty did not document each refusal in the medical record and did not inform the resident's physician about the refusals, as required by facility policy. Instead, the nurse reported the refusals to the Registered Nurse Supervisor, assuming that further action would be taken, but no documentation or physician notification occurred. As a result of the incomplete administration of the medication, the resident was not adequately prepared for the colonoscopy, and the procedure had to be rescheduled. The facility's policy required that all medication refusals be documented and that the physician be notified when a medication is refused, but these steps were not followed in this instance.