Failure to Follow Practitioner Orders and Notify of Medication Unavailability or Refusals
Penalty
Summary
The facility failed to follow practitioner orders and its own medication administration policy for a resident with multiple chronic conditions. The resident did not receive Yupelri Inhalation Solution for 18 days due to unavailability, and there was no documentation that the practitioner was notified or that an alternative treatment was provided. Additionally, the resident refused multiple doses of Novolog insulin and Oxycodone over several days, but there was no evidence that the practitioner was informed of these repeated refusals or that alternative treatments were considered, as required by facility policy. Interviews with the resident and spouse confirmed that the resident was not offered alternative options when medications were unavailable or refused. The resident had a history of only using sliding scale insulin at home and refused Oxycodone in the morning due to side effects impacting participation in therapy and social visits. The DON confirmed that the resident did not receive the prescribed medications as ordered and that the necessary notifications and documentation were not completed.