Failure to Notify Responsible Party of Medication Discontinuation
Penalty
Summary
The facility failed to immediately notify a resident's responsible party (RP) when there was a significant change in treatment, specifically the discontinuation of the medication Ativan, as ordered by the physician. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 7, and diagnoses including anxiety disorder, major depressive disorder, and primary hypertension. Documentation review showed that Ativan was discontinued, but there was no record of the RP being notified of this change. The RP later confirmed in an interview that she was not informed about the discontinuation and would have wanted to know, especially as she lived out of state. Interviews with facility staff, including the ADON, DON, and ADM, confirmed that it was the facility's expectation and policy to notify the RP of such significant changes, but this did not occur. The ADON acknowledged the oversight, and both the DON and ADM reiterated that the RP would not have known about the medication change without being contacted. The facility's policy requires notification of the family or legal representative and physician when there is a significant change in the resident's status or a need to alter treatment, which was not followed in this instance.