Failure to Notify Resident Representative of Medication Changes
Penalty
Summary
The facility failed to timely notify a resident's representative of medication changes for a resident diagnosed with dementia and rheumatoid arthritis. The resident, who was cognitively intact according to a recent assessment, experienced increased confusion and lethargy after taking Baclofen, leading to the discontinuation of several medications, including Baclofen. Later, due to ongoing muscle spasms and pain, Baclofen was restarted and its dosage was subsequently increased. However, there was no documentation in the clinical record that the resident's representative was notified of either the restart or the dosage increase, despite special instructions in the resident's profile to notify the family of any medication changes. Nursing notes indicated that the resident became confused and semi-conscious, prompting notification of the physician, DON, and family, and a subsequent reduction in Baclofen dosage. The resident's daughter later requested transfer to the ER after observing slurred speech, and the resident was admitted to the hospital for polypharmacy, acute encephalopathy, and hypertensive urgency, with hospital records linking the altered mental status to increased Baclofen dosing. Interviews confirmed that the family had not been notified of the medication changes, and staff expressed uncertainty about who was responsible for family notification. The facility's policy required prompt notification of the resident's representative for changes in treatment, including new or discontinued medications.