Failure to Review and Act on Hospital Recommendations for Resident Care
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, including medications, at each required visit. A resident with Huntington's Disease and a history of behavioral disturbances, including suicidal ideation, was transferred multiple times to the hospital emergency department following episodes of agitation and self-injurious behavior. Hospital discharge summaries included recommendations to decrease the resident's Abilify dosage due to risks of akathisia, restlessness, and agitation. However, there was no documented evidence that these recommendations were reviewed or acted upon by the facility's physicians. Medical records showed that after each hospital transfer and return, the resident continued to receive the same medication regimen, and there was no documentation of physician evaluation or intervention regarding the hospital's recommendations. The psychiatrist was not notified of the hospital's recommendation to decrease Abilify, and the resident's medication was instead increased by the psychiatrist without knowledge of the hospital's advice. Nursing notes and interviews confirmed that staff did not consistently communicate or document the hospital's recommendations, and physicians could not recall being informed or reviewing the relevant discharge summaries. The lack of physician oversight and failure to review and incorporate hospital recommendations into the resident's care plan resulted in missed opportunities to adjust treatment and monitor the effectiveness of psychoactive medications. The resident continued to exhibit dangerous behaviors, including a fatal incident where the resident jumped from a window. Interviews with facility staff and physicians revealed gaps in communication, documentation, and follow-up regarding the resident's care after hospitalizations.