Failure to Notify Responsible Party of New Medication Prior to Administration
Penalty
Summary
The facility failed to ensure timely notification of a resident's responsible party regarding the initiation of a new medication, Ativan, and the associated risks and benefits prior to its administration. Interviews with the Social Service Director at a local dialysis center revealed that the resident, who had diagnoses including Alzheimer's disease, vascular dementia, chronic kidney disease, and adjustment disorder with anxiety, was prescribed Ativan to be administered before dialysis sessions. The dialysis center staff observed the resident arriving lethargic and requested discontinuation of the medication after several weeks. Documentation showed that the responsible party was not informed about the new medication at the time of its initial administration, and the addition of Ativan was not discussed during a care plan meeting, despite a note indicating that medications were reviewed. Further interviews with the Memory Care Director, Assistant Director of Nursing, and Director of Nursing confirmed that the responsible party was not notified about the prescription of Ativan prior to its administration. The only documentation of notification was a care plan note stating that medications were reviewed, but it did not specify that Ativan had been discussed. The facility's policy required that all changes in a resident's condition, including new medications, be communicated to the responsible party prior to the end of the assigned shift, with documentation of the notification and response. This policy was not followed in this instance, resulting in a deficiency.