Failure to Inform Residents of Psychotropic Medication Changes
Penalty
Summary
Willow Terrace was found to be non-compliant with federal and state regulations regarding the rights of residents to be informed and make treatment decisions. The facility failed to ensure that residents or their representatives were informed of treatment options, as well as the risks and benefits of proposed care, for three residents who were reviewed for psychotropic medications. This deficiency was identified during a survey conducted on January 31, 2025. Resident R142, who was severely cognitively impaired, was prescribed risperidone by a neurology consultant without documentation that the resident or their responsible party was informed of the medication change, its risks, or alternative options. The medication was later discontinued by psychiatry due to the resident already being on another antipsychotic, aripiprazole. Similarly, Resident R139, who was moderately cognitively impaired, was prescribed aripiprazole after discontinuing risperidone, but there was no documentation that the resident or their representative was informed of the change or offered alternatives. The medication was eventually discontinued due to patient refusal. Resident R158, who was severely cognitively impaired, was prescribed olanzapine upon admission, which was later changed to Depakote by psychiatry. Again, there was no documentation that the resident or their responsible party was informed of the medication change, its risks, or alternative options. The Assistant Director of Nursing confirmed the lack of documentation during an interview with surveyors.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R142 and the responsible party were notified of medication recommendations and of the risks and benefits were explained to them. R139 and responsible party were notified of the medication recommendations and of the risks and benefits. R158 and responsible party were notified of the medication recommendations and of the risks and benefits. The psychiatrist documented the reason for changing the medication. An initial audit of the last 2 weeks of psychiatry recommendations was done to ensure if any medication changes were done, the resident and responsible party were notified of the recommendations and of the risks and benefits as well as alternative treatment options. The DON/designee educated the psychiatrist and licensed staff to document reasons for psychoactive medication changes as well as informing residents and responsible party of medication changes and the risks and benefits associated with the change. Alternative treatment options will also be discussed and documented. The DON/designee will audit psychiatry consults to ensure reasons for medication changes are documented and that the resident and responsible party are informed of the medication change as well as the risks and benefits associated with the changes and alternative treatment options. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.