Failure to Notify Physician of Medication Refusals in Resident with Substance Use Disorder
Penalty
Summary
Facility staff failed to notify the attending physician when a resident was refusing prescribed Suboxone, a medication used as part of substance use disorder treatment. The resident, who was admitted for a minimum six-week course of intravenous antibiotics due to septic wounds and endocarditis suspected to be related to drug use, refused nine doses of Suboxone in January and five of eight doses in February. Despite these refusals, there was no documentation that the physician was informed of the missed doses. Additionally, after a note was made by a physician indicating the resident appeared high, there was no report to mental health services or a multidisciplinary meeting prior to the resident experiencing a suspected overdose that required Narcan administration. Interviews with facility staff confirmed that neither the physician nor mental health services were notified of the medication refusals or the concerning behavior prior to the overdose incident.