Failure to Notify Physician and Administration of Resident's Absence and Missed Medications
Penalty
Summary
The facility failed to ensure timely notification of a physician, medical director, and facility administration when a resident did not return as scheduled from a leave of absence (LOA). The resident, who had diagnoses including cerebral infarction, COPD, and adjustment disorder, was expected to return to the facility by 6:00 PM but did not return until nearly ten hours later. Staff did not notify the Director of Nursing Services (DNS), the administrator, the resident's physician, or local authorities as required by facility policy when the resident was missing. The DNS confirmed she was not informed until the following morning, and the physician stated he would have expected to be notified promptly if a resident did not return from LOA. Additionally, the facility failed to notify the provider when the same resident missed scheduled evening medications, including Furosemide, Gabapentin, Quetiapine, and Eliquis, due to the resident's absence. The LPN on duty did not contact the physician or advanced practice registered nurse (APRN) regarding the missed doses, only informing the charge nurse. The physician confirmed that he expected to be notified within one to two hours of missed medications to make appropriate decisions. Facility policies required staff to notify the provider and supervisory staff in the event of a medication administration error, which was not followed in this instance.