Failure to Notify Guardian of Medication and Lab Order Changes
Penalty
Summary
The facility failed to notify a resident's court-appointed guardian of significant changes in the resident's medication regimen and laboratory orders. The resident, diagnosed with Paranoid Schizophrenia, Thyrotoxicosis, and other psychiatric and medical conditions, had a guardian legally authorized to make decisions regarding psychological, psychiatric, and medical care. Despite this, the facility did not document any notification to the guardian regarding changes in the resident's psychotropic medication (Ativan) from as-needed to scheduled dosing, nor changes in the frequency of thyroid-related laboratory tests. The guardian reported not being informed of these changes, despite having previously notified the facility of her status and the need for communication about all changes. Interviews with facility staff confirmed that there was no documentation of the guardian being notified about the medication or laboratory order changes. The Psychiatric Rehabilitation Services Director acknowledged a lack of answers for the guardian's concerns and confirmed missed doses of medication. The Director of Nursing also confirmed that the facility should have notified the guardian and that no documentation of such notification existed. Facility policy requires notification of the resident representative or next of kin within 24 hours of significant changes, but this was not followed in this case.