Failure to Notify Responsible Party of Medication Change
Penalty
Summary
Pennsburg Manor was found to be non-compliant with federal and state regulations regarding the notification of changes in a resident's condition. Specifically, the facility failed to notify the responsible party of a change in medication dosage for a resident diagnosed with heart disease and major depressive disorder. On December 20, 2024, a physician ordered an increase in the resident's anti-depressant medication, Zoloft, from 50 mg to 75 mg. However, there was no documentation to indicate that the resident's responsible party was informed of this change. During an interview on the same day, the Director of Nursing confirmed the absence of documented evidence that the responsible party had been notified about the medication dosage increase. This oversight was identified during an abbreviated survey conducted in response to a complaint, highlighting a failure in the facility's process to ensure proper communication with resident representatives regarding significant changes in treatment, as required by 42 CFR Part 483 and the 28 Pa. Code.
Plan Of Correction
Resident 1's RP was notified of the change in medication dose. The Director of Nursing will complete an audit of all charts for residents who have had an increase in antidepressant medication in the last 7 days ensuring notification compliance. The Director of Nursing or Designee will re-educate nurses on Notification of Changes to the resident RP and that documentation must be completed in PCC. The Director of Nursing or Designee will complete weekly random audits x 60 days ensuring compliance. The results of these audits will be presented at the QAPI meetings for review and/or recommendations. Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.