Failure to Notify Physician of Repeated Medication Refusals
Penalty
Summary
The facility failed to notify a resident's physician of multiple medication refusals, specifically for Eliquis, an anticoagulant prescribed to the resident. The resident, who was cognitively intact and had diagnoses including hypertension, orthopedic aftercare, and peripheral vascular disease, expressed a dislike for taking Eliquis. Review of the Medication Administration Record (MAR) showed that the resident refused several doses of Eliquis over multiple days, including both morning and evening doses. Despite these repeated refusals, there was no documentation that the physician had been informed, as required by facility policy, which states that the physician should be notified if two consecutive doses are withheld or refused. The Director of Nursing confirmed during an interview that the physician should have been notified of the medication refusals. The deficiency was identified through record review and staff interviews.