Failure to Notify POA of Medication Change
Penalty
Summary
The facility failed to notify the emergency contact and Power of Attorney (POA) of a change in medication for a resident who was unable to make healthcare decisions independently. The resident, who had a history of disorientation and poor judgment, was discharged from the hospital with specific medication orders. However, the facility's physician altered the medication regimen without informing the resident's son, who was the designated healthcare surrogate and POA. This change in medication affected the resident's alertness and ability to participate in daily activities, as reported by the family. The facility's policy required that when a resident was incapable of making decisions, their representative should be informed of any changes. Despite this, the Unit Manager of the Specialized Subacute Unit acknowledged that the resident's son was not notified of the medication change, and there was no documentation of such notification in the resident's clinical record. This oversight led to a deficiency in the resident's right to be informed and participate in their treatment decisions, as outlined in the federal regulations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The responsible party for Resident #20 was notified of the dosage adjustment and current medication regime for. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. A review of all recent medication changes over the past 14 days was conducted to ensure responsible parties were notified as required. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Licensed staff (RNs and LPNs) will receive mandatory training on the requirement/policy to notify residents and/or responsible parties of medication changes and the facility's Notification of Changes Policy, ensuring clear expectations for timely documentation. All Licensed staff will be in-service by. Any Licensed staff not in serviced by this date will be in-service prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or designee will conduct audits of medication changes Monday thru Friday for 2 weeks, then 10 monthly for three months, to ensure responsible party notifications are completed and documented. Any instances of non-compliance will result in immediate re-education and corrective action. Audit results will be reviewed during the facility's monthly Quality Assurance and Performance Improvement meetings. (e) Date of Compliance