Failure to Notify Physician of Behavioral Change After Psychotropic Discontinuation
Penalty
Summary
The facility failed to notify a resident's physician regarding an increase in episodes of yelling after the discontinuation of Seroquel, an antipsychotic medication. The resident in question had a history of dementia, psychosis, hemiplegia, and hemiparesis following a cerebral infarction, and was admitted with severe cognitive impairment and high dependence on staff for daily activities. The physician had discontinued Seroquel, which was previously prescribed for psychotic disorder manifested by yelling. Following the discontinuation of Seroquel, the resident experienced multiple episodes of yelling, as documented in the Medication Administration Record (MAR) over several days. Despite these documented behavioral changes, there was no evidence that the physician was notified of the increased episodes. Interviews with nursing staff confirmed that the episodes were recorded, but the physician was not informed for a psychiatric re-evaluation. A review of the facility's policy indicated that all changes in a resident's condition, including marked changes in mental behavior, should be documented and communicated to the physician and responsible party. However, documentation and interviews confirmed that the required notification and documentation did not occur in this case, resulting in a failure to follow established procedures for change of condition.