Failure to Notify Physician and Family of Change in Resident Status and Missed Medication Administration
Penalty
Summary
The facility failed to immediately inform the resident, the resident's physician, and a family member of a significant change in the resident's status following the dislodgement of a G-tube. The resident, an elderly female with multiple diagnoses including dementia, Alzheimer's disease, diabetes with neuropathy, and a history of heart and vascular conditions, experienced a G-tube dislodgement. Physician orders indicated the need for tube feeding and administration of medications such as Lasix and Plavix via the G-tube. On the day of the incident, the G-tube was replaced and a KUB X-ray was ordered to confirm placement, but medications were not administered during this period. Nursing staff, including LVN A and LVN B, did not administer medications either via the G-tube or orally, despite the resident being on pleasure feedings and potentially able to tolerate oral medications. LVN A reported that he was told to hold all medications based on the outgoing nurse's report, and did not attempt oral administration. LVN B also did not administer medications by mouth, citing the resident's swallowing difficulties and lack of physician clearance, but did not contact the physician to clarify if oral administration was permissible. The physician later stated that she expected to be notified if medications could not be administered and that oral administration was a common alternative, but she was not informed of any issues or missed doses. Facility leadership, including the ADON and DON, confirmed that there was no documentation or communication to the physician regarding the inability to administer medications or the need for alternative routes. The ADON stated that staff were expected to follow up with the physician in such cases, and the DON noted that medications were held, possibly due to concerns about family approval, but expected staff to follow physician orders and document accordingly. The failure to communicate and consult with the physician regarding medication administration during the period when the G-tube was unavailable constituted the deficiency.