Failure to Document and Treat Change in Condition and Follow Physician Orders for Medication
Penalty
Summary
The facility failed to ensure that a resident's change in condition was appropriately documented and treated after the resident missed multiple doses of a prescribed medication. One resident with moderately impaired cognition and diagnoses including dementia and anxiety had an order for Lorazepam (Ativan) to be administered every 12 hours for anxiety. The resident missed several consecutive doses of Ativan due to the medication not being reordered in a timely manner, despite facility policy requiring medications to be reordered before running out. After receiving Ativan following a 48-hour lapse, the resident became unresponsive to questions, with low blood pressure and pulse, prompting a call to emergency services. The nurse involved did not communicate the change in condition to the oncoming shift or the DON, and no follow-up assessments were completed, contrary to facility policy requiring prompt notification and documentation of changes in condition. Additionally, the facility failed to follow physician orders regarding pain medication for another resident with multiple diagnoses, including peripheral vascular disease, hemiplegia, and pressure ulcers. This resident had orders for both scheduled and as-needed Hydrocodone-Acetaminophen (Norco) for pain management, as well as regular pain assessments. The resident did not receive the prescribed Norco doses for an extended period after coming off hospice care, and the medication was discontinued by a nurse without a physician order. Pain assessments were also missed on several shifts, and the DON was not aware of the discontinuation or the missed doses until after the fact. Facility policy requires medications to be administered as prescribed and prohibits discontinuation without a physician's order. Interviews with staff and the residents' physician confirmed expectations that medications should be reordered in advance and that changes in condition or medication status should be communicated promptly to ensure continuity of care. The failures identified included lack of timely medication reordering, inadequate communication between staff, failure to document and assess changes in condition, and unauthorized discontinuation of prescribed medications.