Failure to Notify Representatives of High-Risk Medication Changes
Penalty
Summary
The facility failed to notify the representatives of two residents with severe cognitive impairment about significant changes in their medication regimens. For one resident with diagnoses including anxiety, depression, and hypertension, a new order for quetiapine (an antipsychotic) was initiated, but there was no documentation that the resident's representative was informed or that consent was obtained. For another resident with Alzheimer's Disease, hypertension, and coronary artery disease, trazodone was discontinued and restarted at a different dose and frequency, yet again, there was no record of notification to the resident's representative regarding this medication change. Facility policy requires that residents or their representatives be informed of the benefits, risks, and alternatives prior to initiating or increasing medications, and that they have the right to refuse medications. Staff interviews confirmed the expectation that representatives should be notified of medication changes. However, clinical record reviews for both residents showed a lack of documentation of such notifications, constituting a failure to ensure that residents' representatives were fully informed about their health status, care, and treatments.