Failure to Notify Provider of Missed Medications and Treatment Refusals
Penalty
Summary
Facility staff failed to notify the provider when two residents either refused or did not receive their prescribed medications and treatments. For one resident with orders for lactulose and Albuterol, staff documented that the resident refused lactulose and only took one puff of Albuterol instead of the ordered two. However, there was no documentation that the provider was notified of these refusals or partial administration, as confirmed by both the LPN and RN involved, as well as the Director of Nursing. The medical record only reflected the refusal and partial dose, not the required provider notification or documentation of such communication. For another resident with a diagnosis of edema and an order for compression stockings, staff did not consistently apply the stockings as ordered and failed to document their application in the treatment administration record. Interviews revealed that the resident often refused to wear the stockings, but there was no documentation of these refusals or any notification to the provider regarding the resident's non-compliance with the order. The DON confirmed that provider notification was expected in such cases, but it was not done or documented.