Failure to Document and Communicate Medication Refusals and Omissions
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, diabetes, and dependence on dialysis did not receive medications and treatments as ordered, and staff failed to document and communicate these omissions and refusals appropriately. The resident reported not receiving required medications, including Sevelamer and insulin, after meals. Staff interviews revealed that a Certified Medication Technician (CMT) did not offer the Sevelamer at lunch after the resident refused it at breakfast, and incorrectly documented that the medication was administered at both meals. The CMT also failed to inform the charge nurse or unit manager about the resident's refusal and the omission of the medication. Additionally, the resident did not receive blood glucose monitoring or sliding scale insulin after lunch as ordered, due to the assigned nurse being occupied with other care tasks. The nurse did not communicate this missed care to management. The resident's care plan was not updated to address the ongoing refusal of medications, as the care plan coordinator was unaware of the issue. The facility's policies on insulin administration and medication administration did not address sliding scale insulin, and staff did not follow procedures for timely administration and accurate documentation. Facility leadership, including the unit nurse manager and Director of Nursing, confirmed that refusals and omissions should have been documented correctly and communicated to management, and that the resident's care plan should have addressed medication refusals. The Medication Administration Record (MAR) showed inaccurate documentation, and the timing of insulin administration was not consistent with policy or physician orders.