Failure to Inform Resident Representative of Psychotropic Medication Risks
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and diagnoses including anxiety disorder and major depressive disorder was fully informed of treatment and medication changes. A review of the resident's record showed that the resident was receiving lorazepam as needed for restlessness, as ordered by a physician. The care plan documented the use of anti-anxiety medication and included interventions such as assessing anxiety levels and administering medication per physician orders. However, there was no documentation that the resident or their representative had been notified or educated about the risks and benefits of psychotropic medication use, as required by facility policy. Interviews with staff confirmed that the resident was receiving lorazepam, but the DON was unable to locate any record of notification to the resident's representative regarding the risks associated with psychotropic medication. The facility's policy specifically states that residents and/or their representatives must be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments. This lack of documentation and communication led to the deficiency cited during the survey.