Failure to Notify Physician of Repeated Medication Refusals Leading to Resident Altercation
Penalty
Summary
The facility failed to follow its own policy and procedure regarding physician notification for a resident who repeatedly refused an ordered medication. Specifically, a resident with a physician's order for Buspirone to manage anxiety and unprovoked physical aggression refused the medication multiple times over several months, with documented refusals ranging from 55 to 57 times per month. Despite the facility's policy requiring the attending physician to be notified after two or more consecutive refusals, there was no documented evidence that the physician was informed of these refusals. As a result of the ongoing medication refusals, the resident exhibited aggressive behavior, including a physical altercation in which the resident grabbed another resident's arm, causing a skin tear and bleeding. Staff interviews confirmed the resident's history of aggressive behavior and the need for a one-on-one sitter. The Director of Nursing reviewed the records and confirmed that the policy for physician notification was not followed.