Failure to Address Family Concerns of Overmedication and Opioid Side Effects
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not timely and appropriately assessing family concerns regarding possible overmedication. The resident, who had diagnoses including Alzheimer's disease, dementia, bipolar disorder, and was on hospice care with a prognosis of less than six months, was prescribed tramadol 50 mg twice daily for pain, along with non-pharmacological interventions as tolerated. Despite documentation in the medical record and pain assessments indicating the resident had no pain, the resident continued to receive scheduled opioid medication. Observations showed the resident was frequently sleeping and difficult to arouse, and the family reported concerns about excessive sedation and weight loss, requesting that pain medication be limited to nighttime or as needed for pain. Interviews with staff confirmed that the resident continued to receive tramadol twice daily, and the DON acknowledged awareness of the family’s concerns but had not directly communicated with the family or adjusted the medication regimen. The facility lacked a policy related to opioid medication or management of over-sedation, and there was no evidence that the family’s request or the resident’s condition was promptly or adequately addressed.