Failure to Provide Timely Physician Follow-Up and Medication Reconciliation
Penalty
Summary
The facility failed to provide timely and appropriate treatment and care in accordance with physician orders and professional standards for two residents. For one resident with end stage renal disease and a history of urinary tract infection, the resident complained of burning pain on urination. Although the physician was notified of this change of condition, there was no documentation that nursing staff made follow-up calls to the physician when a response was not received, nor was there timely documentation in the progress notes. The physician's order for an antibiotic was not obtained until more than 48 hours after the initial complaint, and there was no evidence that any diagnostic tests were ordered to confirm the infection. Facility policy required prompt notification and documentation of changes in condition, but these steps were not followed. Another resident, admitted with a diagnosis of pneumonia and requiring antibiotics, did not receive a scheduled dose of amoxicillin-clavulanate as ordered upon admission. The discharge instructions from the hospital specified the timing for the next antibiotic dose, but the medication was not started until the following morning, resulting in a missed dose. The medication was available in the facility's emergency kit, but the admitting nurse did not transcribe the order correctly, causing a delay in administration. Facility policy required accurate medication reconciliation upon admission to ensure continuity of care, but this process was not completed as required. Interviews with facility staff, including the Infection Preventionist, Director of Nursing, and Medical Records Director, confirmed that the required follow-up actions and documentation were not performed in both cases. The failures to follow up with the physician and to reconcile and administer medications as ordered resulted in delays in treatment for both residents. Facility policies on change of condition, documentation, and medication reconciliation were not adhered to, as evidenced by the lack of timely communication, documentation, and medication administration.