Failure to Notify Physician and Responsible Party of Medication Issues and Changes
Penalty
Summary
Facility staff failed to notify physicians and responsible parties as required in three cases. In the first case, a resident with hemiplegia and moderate cognitive impairment did not receive prescribed Lidocaine patches on multiple occasions due to unavailability. The electronic medication administration records (eMARs) showed several instances where the medication was not available, but there was no documentation in the progress notes regarding these missed doses or any notification to the physician or responsible party. Interviews with staff revealed inconsistent understanding and application of the notification process, and the facility's own policy required immediate physician notification and documentation when medications were unavailable, which was not followed. In the second case, a resident with moderate cognitive impairment received a new order for Valacyclovir to treat herpes labialis. Although the medication was administered as ordered, there was no evidence in the clinical record that the resident's representative was notified of the new medication order. Staff interviews confirmed that notification of the resident representative is expected when new medications are started, but this was not documented or carried out in this instance. The third case involved a resident with severe cognitive impairment who refused multiple scheduled medications over a three-month period. The eMARs documented repeated refusals, but there was no evidence that the physician or responsible party was notified of these refusals, as required. Staff interviews indicated that notification should occur with each refusal, especially for residents unable to make their own decisions, but this was not consistently done or documented. The facility's policy required notification of changes, including medication refusals, but this was not adhered to in the resident's care.