Failure to Notify Provider of Medication Refusals and Held Doses
Penalty
Summary
The facility failed to meet professional standards of practice for medication management for one of three residents reviewed. Specifically, staff did not notify the physician or provider when a resident repeatedly refused prescribed medications, including atorvastatin and carvedilol, or when medications were held due to blood pressure readings. Documentation showed that the resident refused atorvastatin on multiple occasions across two months and that carvedilol was either refused or held several times, sometimes due to blood pressure readings. However, there were no documented notifications to the physician or provider regarding these refusals or the holding of medications. Additionally, the order for carvedilol did not include parameters for when the medication should be held based on blood pressure readings, yet staff held the medication for various blood pressure values without provider guidance. The Director of Nursing confirmed that staff did not contact the physician or provider about the resident's medication refusals or about concerns regarding blood pressure readings, despite the expectation that such communication should occur. The resident involved had diagnoses including cerebrovascular disease, essential hypertension, and hyperlipidemia.