Failure to Notify Resident Representative of Medication Discontinuation
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the medication regimen for one of three residents reviewed. Specifically, a resident with diagnoses including Chronic Obstructive Pulmonary Disease, Alzheimer's Disease, and Chronic Atrial Fibrillation had their Xarelto (a blood thinner) discontinued, but there was no documentation that either the resident or the resident's Power of Attorney was informed of this change. The facility's policy requires prompt notification of the resident and their representative when there is a change in treatment, such as discontinuation of medication. Interviews and record reviews confirmed that neither the resident's Power of Attorney nor the resident's spouse, who was actively involved in care, were notified of the discontinuation. The administrator acknowledged entering the verbal order to discontinue the medication but did not notify the resident or their representative, believing hospice should have handled the notification. The hospice nurse practitioner and the spouse also confirmed they were not aware of the medication change, and the clinical record lacked evidence of required notifications.