Failure to Notify Provider of Missed Anti-Convulsant Doses
Penalty
Summary
Nursing staff failed to notify the provider when a resident with a diagnosis of epilepsy did not receive prescribed anti-convulsant medications as ordered. The facility's policy required nurses to inform the attending physician or on-call physician when there was a significant need to alter medical treatment or when a resident refused treatment or medication two or more consecutive times. Despite this, there was no documentation that the provider was notified on multiple occasions when the resident missed doses of Oxcarbazepine and Lamotrigine. Review of the Medication Administration Record (MAR) for the month showed that the resident did not receive several scheduled doses of Oxcarbazepine and Lamotrigine, with nurses documenting the missed doses using a code indicating 'other, see nursing note.' However, nurse progress notes did not contain evidence that the provider was informed about these missed doses. Interviews with nursing staff confirmed that medications were not administered because they were not available, and the provider was not notified as required by facility policy. The Director of Nursing acknowledged that the expectation was for nurses to notify the provider and document both the notification and the provider's response in the nurse's notes when medications were unavailable. This process was not followed, resulting in a failure to communicate significant changes in the resident's medication regimen to the provider as required.