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F0552
D

Failure to Inform Responsible Party of Psychiatric Care and Medication Changes

Dana Point, California Survey Completed on 05-29-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the responsible party for one of six sampled residents was informed in advance about the care to be furnished and the type of provider who would be delivering that care. Specifically, the responsible party was not notified prior to psychological tests, psychiatric visits, or the prescription of buspar by the psychiatrist following a resident-to-resident altercation. The facility's policies require that residents and their responsible parties be included in care planning and notified of changes in care or treatment, but these procedures were not followed in this instance. The resident involved had advanced dementia and was readmitted to the facility prior to the incident. Documentation from a care conference with the responsible party did not mention upcoming psychiatric interventions or medication changes. Interviews with facility staff and the psychiatrist confirmed that the responsible party was not informed in advance about the psychiatric evaluation, follow-up visits, or the new medication order. The psychiatrist indicated that he believed it was the facility's responsibility to obtain informed consent, and the responsible party expressed concerns about not being notified about these aspects of the resident's care.

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