Failure to Notify Responsible Party of New Antibiotic Order
Penalty
Summary
The facility failed to immediately notify a resident's responsible party when a new antibiotic was ordered to treat a urinary tract infection. The resident, an elderly male with severe cognitive impairment, dementia, and an indwelling catheter, was started on Sulfamethoxazole-Trimethoprim for a UTI after a positive urine culture. Review of the medical record and progress notes showed no documentation that the family was informed of the new medication order, despite facility policy requiring notification and documentation of significant changes in condition or treatment. Interviews with the RN who confirmed the order and the DON revealed that the expectation was for nursing staff to notify family members of new medication orders before administration and to document this communication. The RN acknowledged not remembering to notify or document family notification, and the DON confirmed that there was no record of the family being informed. The facility's policy also specified that both the physician and responsible party should be notified and that such notifications should be documented, which was not done in this case.