Failure to Document Medication Refusals and Notify Providers
Penalty
Summary
The facility failed to ensure accurate documentation of medication refusals and appropriate notification to medical providers and responsible parties for one resident. Over a period spanning from May to June, the electronic Medication Administration Record (eMAR) showed multiple instances where the resident refused various prescribed medications, including seizure medications, antihypertensives, vitamins, and supplements. Despite these refusals being recorded in the eMAR, there was no corresponding documentation in the resident's progress notes indicating that the physician (MD), nurse practitioner (NP), or responsible party (RP) had been notified of these refusals. Interviews with nursing staff, including LVNs and the ADON, confirmed that the facility's expectation was for nurses to document medication refusals in the progress notes and to notify the MD, NP, and RP each time a refusal occurred. Staff acknowledged that failure to document these actions constituted a gap in care and could result in a lack of follow-up or intervention. The interviews also revealed that the responsibility for documentation rested with both the charge nurse and the nurse administering the medication, and that the absence of documentation implied that the required notifications likely did not occur. Further, the facility was unable to provide a policy on documentation when requested. The administrator and DON both stated that proper documentation and notification were essential for ongoing patient care and that medication refusals should be treated as a change in condition, requiring thorough documentation and communication. The lack of documentation in this case meant that the medical team was not fully informed about the extent of the resident's medication refusals, particularly for critical medications such as those for seizure control.