Failure to Notify Physician of Resident's Refusal of Lab Work
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to notify the physician of a change in condition for one resident who refused ordered bloodwork. The resident, admitted with diagnoses including seizures, moyamoya disease, and cerebral infarction, had a physician order for valproic acid and laboratory tests. Documentation showed that the resident refused the required bloodwork, but there was no evidence in the clinical progress notes that the physician was informed of this refusal. The Director of Nursing confirmed during an interview that staff did not notify the physician about the resident's refusal of lab work.