Failure to Notify Physician and Representative of Change in Condition and Medication Refusals
Penalty
Summary
Facility staff failed to notify the physician and resident representative of changes in a resident’s condition and treatment status as required by facility policy. The facility’s policy on Change in a Resident’s Condition or Status, revised 02/2021, directed staff to promptly notify the resident, attending physician, and resident representative of changes in medical or mental condition, discovery of injuries of unknown source, significant changes in condition, and refusal of treatment or medications two or more consecutive times. For one resident admitted from home with hospice services for a planned five-day stay, staff documented an incident in which a CNA alerted an LPN to a lump on the resident’s left forehead. The LPN assessed the resident as alert and oriented, with a lump present, no discoloration, no pain or discomfort, and no other identified injuries. The incident report and medical record contained no documentation that the physician or resident representative were notified of this potential injury of unknown source. The same resident’s POS listed multiple scheduled medications, including aspirin, midodrine, diazepam, propranolol, senna, tamsulosin, and carbidopa-levodopa. The MAR showed that on one day, the resident refused all of these scheduled medications. There was no documentation that the physician, hospice physician/staff, or resident representative were notified of the medication refusals. In interviews, the administrator stated staff could not determine the cause of the forehead lump and acknowledged an expectation that the nurse notify the on-call physician, hospice physician, and resident representative of both the lump and the medication refusals. The LPN involved stated he/she did not know what caused the lump and admitted he/she should have notified the physician and resident representative but became busy and forgot. The resident representative, attending physician, and hospice physician each reported they had not been notified of the lump or the medication refusals and stated they would have expected such notification.
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