Failure to Consult Physician for Medication Discontinuation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not consult with the resident's physician regarding the discontinuation of Depakote at the request of the resident's representative. The resident, who had diagnoses including Alzheimer's Disease and unspecified dementia, was dependent on staff for most activities of daily living and was unable to communicate effectively. The medication administration record showed that Depakote was administered as ordered until the day the resident refused a dose and later became unresponsive. Documentation revealed that the Director of Nursing attempted to contact the primary care provider's office for discontinuation orders but was unable to reach them as the office was closed for the weekend. There was no follow-up note indicating that further action was taken to obtain the necessary physician orders for discontinuation. The resident's representative reported not being updated by the facility and only learned of the resident's unresponsiveness and subsequent death after calling to follow up. The facility's charge nurse job description included the responsibility to communicate with the resident's point of contact regarding status updates or changes in condition, which was not documented as having occurred in this case.