Failure to Notify Resident Representative of Medication Changes
Penalty
Summary
The facility failed to inform a resident's representative in advance about proposed care, specifically regarding changes in prescribed medications, including the risks and benefits associated with those medications. Review of the clinical record for a resident with severe cognitive impairment and multiple diagnoses, including traumatic subarachnoid hemorrhage, dysphagia, diabetes, and seizures, showed that there were several changes to the resident's medication orders, such as adjustments to Ativan and Haldol dosages. Despite facility policy requiring notification and documentation of such changes, there was no evidence that the resident's representative was notified or that discussions occurred regarding the advantages, disadvantages, or alternative options for the medication changes. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the facility did not inform the resident's representative as required. The deficiency was identified through review of nurse progress notes and psychiatry recommendations, which lacked documentation of any communication with the resident's representative about the medication changes. This failure was found to be noncompliant with state regulations regarding resident rights and care policies.