Failure to Notify Physician After Repeated Refusal of Vital Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure a resident was free from significant medication errors by not notifying the physician after repeated refusals of vital psychotropic medications. The resident had documented diagnoses of schizophrenia, bipolar disorder, history of alcohol abuse, medical noncompliance, and severely impaired cognition. Multiple clinical documents, including the history and physical, psychiatry evaluations, and physician progress notes, indicated the resident lacked capacity to make medical decisions, had a history of refusing care, and was being treated with Depakote for bipolar disorder and risperidone for paranoid schizophrenia. Review of the resident’s care plan showed a problem for altered behavior patterns related to schizophrenia and psychotropic medication use, with an intervention to notify the physician of any risk or consequences related to non-compliance. The physician’s orders included Depakote 500 mg, two tablets at bedtime for bipolar disorder, and risperidone 3 mg every 12 hours for paranoid schizophrenia. Review of the Medication Administration Record for the month showed that Depakote doses were refused on nine occasions and risperidone doses were refused multiple times for both morning and evening administrations over the review period, including several instances of refusals on three or more consecutive days. Interviews with an LVN and the DON confirmed that facility policy titled “Preparation and General Guidelines” required physician notification when consecutive doses of a vital medication were refused, and that nursing staff were to document the notification and the physician’s response. The LVN stated that if the resident refused Depakote and risperidone for at least three consecutive days, the physician should be notified and the response documented. The DON, upon review of nursing progress notes for the same period, stated that there was no documentation showing that a physician had been notified about the resident’s repeated refusals of Depakote and risperidone. The DON further acknowledged that without such notification, the physician would assume medications were being administered and would not know what other interventions to order, confirming that the required notification and documentation did not occur.
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