Failure to Notify Physician and Resident Representatives of Medication Refusals and New Orders
Penalty
Summary
The facility failed to notify residents' physicians and resident representatives of significant changes in condition and new medication orders for three residents. For one resident with intact cognition and diagnoses including bipolar and schizoaffective disorders, there were multiple refusals of a prescribed antipsychotic injection over several weeks. These refusals were documented in the Medication Administration Record, but there was no documentation in the progress notes regarding the refusals, nor evidence that the physician or family had been notified. Interviews with nursing staff and the Director of Nursing confirmed that the required notifications did not occur and were not documented. For two other residents with cognitive impairments and complex medical histories, new medication and treatment orders were initiated in response to changes in their conditions, such as skin rashes and inflammation. Progress notes documented the new orders but did not indicate that resident representatives had been informed of these changes. The Director of Nursing confirmed that there was no evidence of notification to the resident representatives, despite facility policy requiring such communication when there is a need to alter a resident's medical treatment.