Failure to Notify Providers of Unadministered and Refused Medications
Penalty
Summary
The facility failed to notify providers in a timely manner when prescribed treatments and medications were not administered as ordered for two residents. For one resident with severe cognitive impairment and multiple complex diagnoses, including epilepsy and cancer, there were several missed doses of phenobarbital documented in the Medication Administration Record (MAR) over multiple dates. The MAR indicated missed doses using a chart code, and progress notes showed that the medication was on order and not yet delivered. However, there was no documentation that the provider was notified of these missed doses until several weeks later, and for some missed doses, no provider notification was documented at all. For another resident with moderate cognitive impairment and multiple medical and psychiatric conditions, including anorexia nervosa, malnutrition, and gastrointestinal disorders, there were missed and refused doses of intravenous nutritional support (Clinimix and Clinolipid) documented in the MAR. The chart codes indicated both unadministered and refused doses, but there was no documentation in the progress notes that a provider was notified of these events. Interviews with staff, including a unit manager and the Director of Nursing (DON), confirmed that provider notification and documentation were expected but not completed or recorded in these cases. Facility policy required that the attending physician or nurse practitioner be notified of changes in condition or when medical intervention was warranted, and that such notifications be documented in the medical record. The DON and other staff acknowledged that the medical record should reflect all care provided, including provider notifications, and that the lack of documentation was not consistent with facility policy. Interviews with providers did not confirm that they had been notified of the missed or refused medications, further supporting the finding that timely provider notification and documentation did not occur.