Failure to Notify Responsible Parties of Medication Changes
Penalty
Summary
The facility failed to notify the responsible parties of three residents regarding the initiation and changes to their medication regimens. Resident #42, who was diagnosed with Dementia, Adjustment Disorder, Delusional Disorder, Depression, Anxiety, and Schizophrenia, was deemed incapable of making decisions, and a guardian was appointed. Despite changes in her medication, including the initiation and dosage increases of Cymbalta and Buspirone, there was no documentation indicating that the guardian consented to these changes. Resident #68, diagnosed with Dementia, Adjustment Disorder, Anxiety, Depression, and Psychotic Disorder, also had a guardian appointed due to his inability to make decisions. He was administered Haldol for severe agitation without documentation of guardian consent or notification of the events leading to the administration. The resident exhibited aggressive behavior, necessitating the emergency use of Haldol, but the facility failed to inform the guardian about this medication change. Resident #75, with diagnoses including Vascular Dementia, Alzheimer's, Adjustment Disorder, Psychotic Disorder, and Depression, was also incapable of making decisions, with her daughter as the responsible party. Changes in her medication regimen, including the initiation and dosage adjustments of Lorazepam and Klonopin, were made without documented consent from her daughter. The facility's policy required notification and documentation of such changes, but these were not adhered to, leading to the deficiency.
Plan Of Correction
1. Res. #42's responsible party was notified and agreed to use of anti-depressant and anti-anxiety medications. Update was given to responsible party on all changes and adjustments that have been made. Res. #68's responsible party was contacted and consent was obtained for use of anti-psychotic medication. Responsible party was also updated on all recent changes or adjustments and behaviors. Res. #75's responsible party was notified and agreed to use of anti-anxiety medication. Update was given to responsible party on all changes and adjustments that have been made. 2. Social Service Designee reviewed other residents in the building receiving psychotropic medications to ensure appropriate notification and consents were received. 3. Notification of Change Policy and Procedure was reviewed by the IDT team. All Nurses, RD, and Social Service Designee were in-serviced on the Notification of Change Policy. 4. Director of Nursing or designee will audit 25% of all psychotropic medication new orders in stand-up meetings weekly x4, then monthly x2 to ensure that notification and consent was obtained. Any concerns will be addressed. Results of the audit will be reported to QA monthly. The Director of Nursing will be in charge of sustained compliance. 5. Director of Nursing or designee will audit 25% of the residents currently on psychotropic medications to ensure the responsible party was contacted and consented to anti-psychotics and agreed to anti-anxiety and anti-depressant medication. Responsible party was also updated on all recent changes or adjustments and behaviors weekly x4, then monthly x2 to ensure that notification and consent was obtained. Any concerns will be addressed. Results of the audit will be reported to QA monthly. The Director of Nursing will be in charge of sustained compliance.