Failure to Document Medication Refusal and Provider Notification
Penalty
Summary
A deficiency was identified when a resident, admitted with urinary retention and acute kidney injury, refused a prescribed dose of Atenolol, a medication used to treat high blood pressure. The resident's Minimum Data Set indicated intact cognitive skills and varying levels of assistance required for daily activities. During a medication pass, the resident's systolic blood pressure was measured at 108 mmHg, above the threshold for holding the medication, but the resident refused the dose, stating his blood pressure was acceptable. The facility's Medication Administration Record did not document the reason for the missed dose or the notification of the Nurse Practitioner regarding the resident's refusal, as required by facility policy. Interviews with the administering RN and the Clinical Nurse Manager confirmed that the NP was not notified and that this omission was not documented. Facility policy specifies that any refusal of medication and physician notification must be recorded in the MAR, but this was not done in this instance.