Failure to Notify Resident's Representative of Medication Changes
Penalty
Summary
The facility failed to notify the representative of a resident about changes in their medication regimen, which is a requirement under the facility's policy. The resident, who had diagnoses including dementia, anxiety, insomnia, and Alzheimer's disease, was undergoing a gradual dose reduction of Seroquel, an antipsychotic medication, and the initiation and subsequent discontinuation of Sertraline, an antidepressant. Despite these significant changes in the resident's plan of care, there was no documentation indicating that the resident's representative was informed of these changes. Interviews with facility staff revealed a lack of communication and responsibility regarding the notification process. The Assistant Director of Nursing acknowledged that the family should have been notified by the physician, but this did not occur, partly due to the attending physician's departure from the facility. Attending Physician #2 and the Psychiatric Nurse Practitioner involved in the resident's care also did not recall notifying the family, highlighting a breakdown in the communication process within the facility's interdisciplinary team.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 580 Notification of Changes I: The Following Actions were accomplished for the residents identified in the Sample: ? Resident #400 expired on (MONTH) 13, 2024. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ? All residents have the potential to be affected by the same practice. ? The Director of Nursing/Designee will complete chart reviews of other residents with psychoactive medication changes from (MONTH) 2024 till present to ensure all resident’s family or representative were notified of any changes on psychoactive medications. III: The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: ? The Administrator and Director of Nursing reviewed the policy entitled “Psychoactive Drugs” on (MONTH) 17, 2024, and no revision is needed. ? The Licensed Nurse Educator/Designee will provide education to all licensed nurses on the existing policy for Psychoactive Drugs. ? The Attending Physician #2 was also provided one to one education by the Licensed Nurse Educator/ADON of the responsibility to notify the Resident’s family or representative of any psychoactive medication changes. ? The Medical Director will also complete the educational in-service to all medical providers. ? The Staff Educator/Designee will create a lesson plan regarding Psychoactive Medication changes. The lesson plan will be discussed with all licensed nurses to ensure compliance with the policy for Psychoactive Medication. IV: The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: ? Director of Nursing/Designee will develop an audit tool entitled “Psychoactive Medication Notification of Changes.” The audit tool will be utilized to monitor compliance with family or representative notification for any psychoactive medication changes. The audits will be conducted weekly for 3 months. ? A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Director of Nursing. Responsible: Director of Nursing is responsible for ensuring all above is completed.