Failure to Notify Physician of Missed Orders and Treatment Changes
Penalty
Summary
The facility failed to notify the physician when there was a need to alter treatment for two residents. For one resident, who had diagnoses including pyelonephritis, head injuries, and quadriplegia, a physician ordered a UTI Panel to be obtained before starting antibiotics. The medical record showed that the urine specimen was not collected as ordered, and there was no documentation that the physician was notified of this omission before antibiotics were started. Interviews with nursing staff and administration confirmed that the specimen was not obtained and the physician was not informed prior to initiating treatment. For another resident with a history of traumatic brain injury, bipolar disorder, anxiety, major depressive disorder, and behavioral syndromes, there was a new order for Depakote to be administered twice daily. The resident missed two doses of Depakote due to issues with medication reconciliation and documentation on the MAR. Nursing staff did not notify the physician about the missed doses. The DON confirmed that staff are expected to notify the physician if they are unable to carry out an order, and acknowledged that there was no documentation of physician notification regarding the missed medication.