Failure to Notify Responsible Party of New Medication Order
Penalty
Summary
The facility failed to notify the responsible party of a resident with Alzheimer's disease and dysphagia when a new medication, Namenda, was added to the resident's medication regimen. Despite multiple documented refusals by the responsible party to add Namenda, and clear notes from the APRN indicating ongoing refusal and education provided, the medication was ordered by the physician and subsequently administered to the resident over several months. There was no documentation in the nurses' notes or elsewhere that the responsible party was informed of the new order or the administration of Namenda. Interviews with staff confirmed that the process for new medication orders requires the approving RN supervisor to notify the responsible party and document this notification, which did not occur in this case. The responsible party reported being unaware of the medication change and expected to be notified to provide input on medication management. The facility was unable to provide a policy regarding notification of changes, and staff interviews revealed gaps in the process for reviewing and communicating medication changes during care conferences.