Failure to Notify Physician and Document Medication Refusals
Penalty
Summary
Surveyors identified that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two out of three residents reviewed for medication administration. For one resident with diagnoses including moderate persistent asthma and essential hypertension, the medication administration record showed that a prescribed blood pressure medication was not administered on a specific date, with documentation indicating 'within normal limits' despite no hold parameters being present in the physician's order. Additionally, this resident refused asthma and blood pressure medications on several occasions, but there was no documented evidence that the physician was notified of these refusals as required by facility policy. Another resident, with severe cognitive impairment and diagnoses including dementia and major depressive disorder, refused all oral medications during a shift. The record lacked documentation that the physician was informed of these refusals, contrary to the facility's medication refusal policy. The policy specifies that after three refusals, the physician or appropriate practitioner must be notified and the refusal documented in the resident's record. Interviews with facility staff, including nurses and the Director of Nursing, confirmed that the expected process is to notify the physician or nurse practitioner of medication refusals and to document these events in the resident's chart. However, staff acknowledged that these steps were not consistently followed, with one nurse stating that failure to document a refusal was an oversight. The survey findings indicate that the facility did not adhere to its own policies or professional standards regarding medication administration and documentation.