Failure to Notify Physician of Medication Refusals
Penalty
Summary
The facility failed to notify the physician of a resident's repeated refusals of an ordered medication, specifically furosemide, which is used to remove fluid. According to the facility's policies, staff are required to notify the attending physician when there is a need to alter treatment significantly, such as when a medication is refused. Record review showed that the resident, who was cognitively intact and had diagnoses including Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension, and Congestive Heart Failure, refused furosemide on seven occasions over a ten-day period. There was no documentation in the clinical record indicating that the physician was informed of these refusals. Interviews with nursing staff, including a nurse, the Director of Nursing, and the Nurse Practitioner, confirmed that the physician was not notified of the medication refusals. Staff acknowledged that the physician should have been informed and that the resident should have been educated about the potential adverse effects of refusing the medication. The lack of notification was identified through both record review and staff interviews.