Failure to Notify Physician of Changes in Condition and Medication Holds
Penalty
Summary
The facility failed to consult with physicians regarding significant changes in condition for two residents. For one resident with diabetes and severe cognitive impairment, blood glucose levels were consistently elevated on multiple dates, as documented in the medication administration record. Despite these abnormal readings, there was no evidence that the physician was notified or that sliding scale insulin was considered or ordered. Nursing staff and the DON confirmed that physician notification should have occurred for these abnormal results, and that an order for sliding scale insulin was needed to manage the resident's blood glucose levels. For another resident with congestive heart failure and hypertension, the medication Digox was held on several occasions due to low heart rates, as per physician orders. However, there was no documentation that the physician was consulted about the repeated low heart rates or the pattern of the medication being withheld. Staff interviews confirmed that the physician should have been notified and that such notifications should be documented in the resident's medical record. Facility policy also required physician notification when a dose of medication was not given.