Failure to Notify Physician and Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that medications were administered to meet the needs of a resident and in accordance with professional standards of practice. Specifically, a resident with multiple diagnoses, including depression, schizoaffective disorder, psychosis, anxiety disorder, insomnia, and type 2 diabetes mellitus, experienced multiple episodes of medication refusal involving anticonvulsant, antipsychotic, and insulin medications. Despite care plan interventions requiring physician notification after three consecutive refusals, the physician was not notified of these repeated refusals. The care plan also required monitoring and documentation of noncompliance, as well as education for the resident and family, but these actions were not consistently documented or performed. The resident's Medication Administration Record (MAR) showed numerous refused doses of critical medications over several days, including anticonvulsant, antipsychotic, antidepressant, and insulin. Additionally, insulin was administered on several occasions without obtaining the required blood glucose checks beforehand, contrary to the facility's policy and procedure for medication administration. The Director of Nursing (DON) confirmed that the physician was not notified of the refusals and that licensed nurses did not document education provided to the resident regarding medication refusals. The DON also acknowledged that the Interdisciplinary Team (IDT) did not address the resident's refusal of blood glucose checks and medication refusals as required by policy. A review of the facility's policies indicated that documentation of medication refusals should include the date and time, the medication refused, the resident's reason for refusal, the name of the person attempting administration, information provided to the resident about the consequences of refusal, the resident's condition, and notification of the attending physician. The policies also required that vital signs or testing, such as blood glucose monitoring, be completed and recorded prior to medication administration. These procedures were not followed, resulting in deficient practice related to medication administration and documentation.