Failure to Notify Physician and Emergency Contacts of Changes in Condition and Missed Medications
Penalty
Summary
Facility staff failed to notify the emergency contact of changes in condition and the physician of medications not administered for two residents. For one resident, staff did not inform the physician when multiple medications, including antibiotics, antidiabetics, and heart failure medications, were not administered over several months due to reasons such as unavailability or the resident being asleep. Documentation in the electronic medication administration record (eMAR) did not show evidence of physician notification for these missed doses, nor were there parameters in the physician orders for holding medications under certain conditions, such as when the resident was sleeping or had low blood pressure. Additionally, the same resident experienced significant changes in condition, including lethargy, labored breathing, confusion, and low oxygen saturation, as well as another episode of labored breathing and pallor. In both instances, only the resident, who was their own responsible party, was notified, and there was no documentation that the next of kin or emergency contacts were informed, despite facility policy requiring such notification in emergencies or when the resident may not be able to understand the situation. For another resident, who was also their own responsible party, staff failed to notify the next of kin after the resident was found outside the facility, which was considered a change in condition. The resident was returned inside, a wander guard was applied, and safety checks were initiated, but only the resident was notified. Staff interviews confirmed that, according to facility policy, the next of kin should have been notified in these situations, especially when the resident's ability to act as their own responsible party was in question during an emergency.