Failure to Document and Notify PCP When Withholding Medications
Penalty
Summary
The facility failed to document the reasons for withholding medications and did not notify the primary care physician (PCP) when medications were withheld for one resident. The resident, who was admitted with diagnoses including tachycardia, depression, anxiety, and headache, had intact cognition and was responsible for daily decision-making. Medication administration records showed that several doses of prescribed medications, including auvelity, ivabradine, and emgality, were not administered as ordered. The electronic medical record indicated that these medications were held, but there was no documentation explaining the reasons for withholding them or evidence that the PCP was notified. Interviews with the resident, a licensed vocational nurse (LVN), and the director of nursing (DON) confirmed that the medications were withheld and that the required documentation and notifications were not completed. The LVN stated that medications were likely held due to lack of supply, and both the LVN and DON acknowledged that facility policy requires documentation of the reason and PCP notification when medications are withheld. Review of facility policy further confirmed these requirements, but no such documentation or notifications were found in the resident's records.