Failure to Notify Family of Treatment Changes
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative regarding changes in treatment and physician's orders. Specifically, for one resident, there was no documented evidence that the resident's power of attorney and interested family member was informed about new physician's orders for medications prescribed on two separate occasions. The resident, who had a diagnosis of Parkinson's disease and dementia, was moderately impaired and had an Advanced Directive in place, which required staff to keep the family informed of changes in condition. Despite the facility's policy requiring documentation of family notifications, there was no record of communication with the resident's family member about the new orders for Paxil and Anafranil. The Director of Nursing confirmed that the family member was not notified about these changes. This oversight was identified during a review of policies, clinical records, and staff interviews, highlighting a deficiency in the facility's adherence to its own documentation and notification procedures.
Plan Of Correction
1. Resident 7 remains in the facility; residents medical record was reviewed by the physician and medications remain appropriate. Family member is aware of all medication's orders. 2. The Director of Nursing/Designee will review progress notes and 24-hour report daily to ensure notification to resident's representatives are informed of any medication changes and document the notification in the medical record. 3. The Director of Nursing/Designee will educate the Registered nurses on the importance of notifying Resident's representative on any medication changes, and documenting in the medical record of any medication changes. 4. The Director of Nursing/Designee will audit daily by reviewing progress notes and the 24-hour report to ensure notification to Resident's representative on medication changes and documentation was completed on any medication changes. This audit will be completed daily 5 times for two weeks, then three times a week times 2 weeks, then weekly times two weeks, then monthly times two months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met. 5. The completion date will be 02/11/2025.