Failure to Notify Physician of Positive THC Test After Hospitalization
Penalty
Summary
The facility failed to notify a resident's physician following a significant change in condition, specifically after the resident tested positive for THC at the hospital. The resident, an adult female with a history of lumbar fracture, paraplegia, asthma, and COPD, was sent to the hospital for altered mental status. Hospital records indicated a positive THC drug screen and a diagnosis of THC overdose, with additional documentation of a history of marijuana use. The resident did not have a physician order for THC, and her care plan did not address substance abuse. Interviews with facility staff revealed that while some staff were aware of the resident's altered mental status and suspected drug ingestion, there was no evidence that the physician was notified of the positive THC result. The DON at the time was not employed during the incident, and the Interim DON stated she was not verbally notified by the hospital nor did she review the hospital report. The admissions nurse was identified as responsible for reviewing hospital records, but there was no confirmation that this occurred. Nursing staff reported inconsistent access to hospital discharge paperwork, and the physician confirmed she was not made aware of the positive drug test. Facility policy required timely communication of significant changes in resident status to the medical staff, including pertinent information from recent hospitalizations. Despite this, the positive drug test and related hospital findings were not communicated to the resident's physician, resulting in a failure to ensure the physician was informed of a significant clinical change.