Failure to Notify Physician and Resident Representative of Changes in Condition and Medication Availability
Penalty
Summary
Facility staff failed to notify physicians and resident representatives of significant changes in condition and medication availability for two residents. For one resident with a history of multiple strokes, heart failure, and other complex medical conditions, staff did not inform the physician about changes in condition or the unavailability of prescribed dexamethasone for pneumonia. Progress notes repeatedly documented that the medication was pending pharmacy delivery over several days, but there was no evidence of physician notification as required by facility policy. Interviews with nursing staff confirmed that the expected protocol was to notify the physician and family if a medication was unavailable or delayed, but this was not followed. For another resident with chronic obstructive pulmonary disease, diabetes, heart failure, and other serious diagnoses, staff failed to notify the physician or nurse practitioner of multiple low blood pressure and pulse readings, as well as ongoing shortness of breath after a breathing treatment. The clinical record showed that the resident had not received several prescribed medications due to unavailability, with documentation indicating medications were on order or awaiting insurance approval. Despite these issues, there was no evidence that the physician or nurse practitioner was informed about the missed doses or the resident's ongoing symptoms. Facility policy required nursing staff to notify the attending physician of unavailable medications and changes in resident condition, explain the circumstances, and seek alternative orders if necessary. Interviews with nursing staff and the interim DON revealed inconsistent understanding and implementation of these procedures. The deficiencies were identified through clinical record review, staff interviews, and policy review, with no documentation of required notifications to physicians or resident representatives in the cases reviewed.