Failure to Notify Provider of Pharmacist Recommendations and Inadequate Injury Monitoring
Penalty
Summary
The facility failed to notify the provider of pharmacist recommendations regarding a resident's bowel regimen and did not monitor or document an injury sustained by the resident. Specifically, the consulting pharmacist repeatedly documented concerns about the resident's use of as-needed cathartic medications and recommended that the bowel regimen be reviewed and possibly modified. Despite these recommendations, there was no documentation that the provider was notified or that any changes were made to the resident's medication orders. The Director of Nursing confirmed that there was no evidence of provider notification or review of the pharmacist's recommendations, as required by facility policy. Additionally, the facility did not adequately monitor or document a resident's injury following an incident in which the resident's arm was bent behind their back, resulting in swelling and bruising. There was no documentation of the incident or monitoring of the resident's arm or psychosocial state for several days after the event. Documentation of the injury and assessment only began several days later, when swelling and bruising were noted and the resident was seen by a provider. The Director of Nursing confirmed that there was no investigation or continued monitoring documented between the time of the incident and the later assessment.