Physician Review and Documentation Lapse for Medication Order
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician reviewed a resident's total program of care, including medications and treatments, at each required visit. Specifically, a resident with a history of chronic constipation was seen by a gastroenterologist, who recommended starting the medication Linzess. However, there was no documented evidence that this medication was ever ordered for the resident, nor was the consultation documentation available in the resident's record for review. The resident in question had multiple diagnoses, including dementia, schizoaffective disorder, and chronic constipation, and was dependent on staff for most activities of daily living. The care plan for constipation included several medications and interventions, and the gastrointestinal consult recommended adding Linzess to the regimen. Despite this, the medication was not ordered, and the consult documentation was missing from the resident's chart. Interviews with facility staff revealed that the process for reviewing and filing consultation documentation was not consistently followed. The DON confirmed the consult was not in the chart and had to be obtained by phone. The LPN described the usual process for handling consults, and the nurse practitioner stated they did not recall seeing the consult or the recommendation for Linzess, despite documenting that the consultation services were reviewed. This lapse resulted in the resident not receiving the recommended medication and incomplete documentation in the medical record.