Failure to Notify Physician of Missed Medication Dose and Delayed Hospital Transfer
Penalty
Summary
Facility staff failed to notify a resident's physician when a scheduled dose of Heparin, prescribed for DVT prophylaxis, was missed. The resident, who had a history of a displaced intertrochanteric fracture and was dependent on staff for activities of daily living, reported to an LVN that her afternoon dose of Heparin was not administered after returning from physical therapy. The LVN confirmed with the nurse responsible for the dose that it had been forgotten, but did not report the missed dose to the registered nurse or the physician, citing fear of being labeled a snitch. The physician was not informed of the missed dose until several days later by the Director of Nursing. Additionally, the facility staff did not notify the physician when the resident was not transferred to a general acute care hospital as ordered. Although the physician had ordered a stat venous doppler and authorized transfer to the hospital for further evaluation, the resident expressed a preference to remain at the facility until the doppler could be completed. The LVN on duty did not inform the physician of the resident's decision to delay transfer, instead planning to endorse the situation to the next shift. The physician only learned of the resident's decision and subsequent transfer the following day. Review of facility policies and job descriptions confirmed that staff were required to report changes in resident condition and medication errors to the physician and appropriate supervisory staff. However, these procedures were not followed, resulting in the physician being unaware of both the missed medication dose and the delay in hospital transfer, as documented in interviews and record reviews.