Failure to Notify POA of Antidepressant Dose Change
Penalty
Summary
The facility failed to notify a resident's power of attorney (POA) regarding a change in the resident's antidepressant medication. The resident, who has diagnoses of dementia and major depressive disorder, had her Zoloft dose decreased from 75 mg to 50 mg without the knowledge or consent of her POA, who is also her daughter. The POA discovered the change after returning from vacation and noticing the resident was tearful and emotional. Upon reviewing the medication record, the POA found the dose reduction and stated she had not consented to it. The medication was later returned to the original dose at the POA's request, and subsequently increased with her consent. Review of the resident's psychotropic consent forms showed that the dose reduction to 50 mg was not documented, nor was there any record of the POA's consent for this change. The facility's resource nurse confirmed that the POA should be notified and consent obtained for any medication changes. The lack of notification and consent for the medication adjustment constituted a failure to follow required procedures for informing a resident's representative of significant changes.