Failure to Notify Responsible Parties and Physicians of Condition Changes and Unavailable Medications
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible parties and physician of significant changes in condition, diagnostic results, medication changes, and incidents, as well as failure to document such notifications. One resident with Alzheimer’s disease, dementia, severe cognitive impairment, and impaired cognition requiring cues and reminders had multiple events in the medical record where no documentation of responsible party notification was present. These events included review of diagnostic testing results, STAT lab orders related to a change in condition and increased pain when the lab could not send a technician and the resident refused hospital labs, medication changes, new orders, a fall in the resident’s room, diagnostic lab reports, orders for additional lab testing and medication discontinuation, and abnormal lab results. The record repeatedly lacked documentation that the resident’s durable POA for healthcare was notified, despite the daughter’s report that neither she nor her sister had been informed of changes in condition, medication changes, or the fall. Staff interviews confirmed that the expectation was to notify the responsible party and physician of changes in condition, labs, and medication changes, particularly for cognitively impaired residents. RNs and the DON stated they would notify the responsible party of any changes in condition, including labs and medication changes, and that cognitively impaired residents would not be considered their own person for notification purposes. The facility’s policy titled “Notification of Change if Condition” required documentation of notification or notification attempts in the electronic medical record and required that the resident and/or representative and medical provider be notified of a change in condition. Despite this policy and staff statements, the medical record for this cognitively impaired resident lacked the required documentation of notifications for multiple significant clinical events. A second deficiency involved failure to notify a physician when ordered medications were unavailable and therefore not administered to another resident. This resident, who had COPD, a history of venous thrombosis/embolism, HTN, CAD, and a history of MI, had orders for azithromycin for COPD and Xarelto for a history of thrombosis/embolism. The MAR showed that the initial 500 mg dose of azithromycin was unavailable and not administered, and there was no documentation that the resident ever received that dose or that the physician was notified of the unavailability. The MAR also showed that Xarelto was unavailable and not administered on two separate days, with no documentation of physician notification. The Clinical Consultant stated that azithromycin was available in the EDK, that the physician should have been notified when medications were not available, and that the nurse should have administered the antibiotic as soon as it arrived, but she could not provide documentation that the antibiotic was given or that the physician was notified. The facility’s “Non-Controlled Medication Orders” policy required nursing to contact the prescriber when delivery of a medication would be delayed or the medication was not available, which was not reflected in the resident’s record.
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