Failure to Notify Physician After Multiple Medication Refusals
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to notify the physician when a resident, who was cognitively intact and had a diagnosis of epilepsy, refused their prescribed anti-seizure medication, Keppra, for three consecutive doses. Medical record review showed that the resident refused both morning and bedtime doses on one day and the morning dose the following day, with no documentation indicating that the physician was informed of these refusals. Staff interview with the DON confirmed the lack of physician notification, and review of facility policy revealed that the nurse is required to notify the physician after two or more consecutive refusals of medication or treatment. This deficiency was identified during a complaint investigation.