Failure to Notify Pulmonary Specialist of Medication Changes
Penalty
Summary
Facility staff failed to notify a resident's pulmonary specialist of medication changes as directed by the primary care provider. The resident, who had chronic obstructive pulmonary disease (COPD) and a history of antibiotic resistance, was admitted with intact cognition and had recently experienced increased shortness of breath and a productive cough. The primary care provider ordered doxycycline and other medications for a suspected COPD exacerbation, but the resident repeatedly refused the antibiotic, citing adverse reactions and later reporting an allergy. Despite the resident's requests and the primary care provider's explicit direction to notify the pulmonary specialist, facility records and electronic health records showed no evidence that the pulmonary specialist was contacted by staff regarding the medication changes or the resident's refusals. Communication logs indicated that the APRN repeatedly asked if the pulmonary specialist had been notified and if there was any response, but staff reported no contact or response from the specialist. The resident ultimately contacted the pulmonologist independently, resulting in a new prescription being faxed to the facility. The deficiency was identified through record review and interviews, which confirmed that the facility did not follow its own policy requiring notification of changes in treatment to the appropriate physician or specialist. The lack of timely communication with the pulmonary specialist occurred despite clear instructions from the primary care provider and ongoing documentation of the resident's medication refusals and reported allergy.