Failure to Notify Guardian of Medication Changes
Penalty
Summary
The facility failed to notify the responsible party of a resident, identified as Resident R71, about changes in the resident's condition, specifically regarding the medication Seroquel. Resident R71 was admitted with diagnoses of pneumonia, major depressive disorder, and sepsis. Concerns were raised by the family about the medication Seroquel making the resident tired, and although the physician and pharmacy confirmed the dosage was appropriate, there was no documentation of notification to the resident's guardian about these concerns and the medication's dosage. The deficiency was confirmed during an interview with the Social Worker, Employee E10, who acknowledged that the guardian was not informed of the changes in the resident's condition as required by regulations. This lack of communication with the resident's guardian regarding medication changes is a violation of the requirement to notify the resident's representative of significant changes in the resident's condition.
Plan Of Correction
Moving forward, the facility will ensure that proper notification to Resident family/RP are completed with changes. Unable to make corrective action for R 71, he no longer resides in the facility. To identify other residents that have the potential to be affected, the Director of Nursing (DON)/designee reviewed progress notes to ensure that notification of changes were complete with resident family and/or Responsible Party. Negative findings will be addressed. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated licensed nursing staff on the regulatory requirements of F580. To monitor and maintain ongoing compliance, the DON/designee will audit progress notes weekly x4 then monthly x 2 to ensure notifications are made. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.