Failure to Notify Medical Provider of Repeated Medication Refusals and Behavioral Incident
Penalty
Summary
A deficiency occurred when a resident with dementia, cerebral infarction, and diabetes, who was prescribed haloperidol for agitation, refused multiple doses of the medication over a period of time. Specifically, from early June to mid-July, the resident refused haloperidol on numerous occasions—29 out of 55 opportunities in June and 17 out of 28 in the first half of July. Despite these frequent refusals, there was no documented evidence that a medical provider was notified about the pattern of refusals, as required by facility policy and physician orders. On July 11, the resident exhibited increased agitation, wandering behaviors, and attempted to exit a bedroom window, resulting in the resident being placed on 15-minute checks. The incident was documented in a 24-hour nursing report and discussed with the DON, but there was no progress note entered in the electronic health record regarding the event, nor was the comprehensive care plan updated. Additionally, there was no documented evidence that a medical provider was notified about the resident's increased agitation and elopement attempt. Interviews with facility staff revealed inconsistent understanding and implementation of the notification process for medication refusals and significant behavioral incidents. The DON acknowledged that a progress note and care plan update should have been completed and expected eventual provider notification, though no specific timeframe was established. Other nursing staff and providers indicated that they would expect prompt notification of refusals and significant incidents, but the medical provider and nurse practitioner confirmed they were unaware of the extent of medication refusals and the elopement attempt until after the fact.