Failure to Address and Document Resident's Medication Refusal Prior to Dialysis
Penalty
Summary
Facility staff failed to ensure that a resident was under appropriate physician care regarding the refusal of prescribed medications prior to dialysis. The resident, who was cognitively intact and able to make daily decisions, consistently refused to take morning medications on dialysis days, believing that the medications would be flushed out during the dialysis process. This refusal was documented multiple times in the medication administration record and nurses' notes, with staff indicating that the physician was aware of the refusals but did not provide new orders or address the issue in the clinical record. Interviews with staff and the physician confirmed that the physician was aware of the resident's ongoing refusal and had discussed the risks with the resident, but failed to document these conversations or provide further education or consultation as recommended by facility policy. The resident reported that no staff, including the physician, had addressed his concerns or refusal of medications. Facility policy requires physicians to supervise medical care, participate in assessment and care planning, and provide consultation or treatment as needed, but these actions were not documented or carried out in this case.