Failure to Notify Resident Representative of Significant Medication Change
Penalty
Summary
The facility failed to immediately notify a resident's representative when there was a significant change in the resident's treatment plan. Specifically, a resident with diagnoses including acute embolism, thrombosis of the right femoral vein, vascular dementia, and a history of cerebral infarction was prescribed Lovenox injections for deep vein thrombosis. The resident, who had severely impaired cognition, refused the Lovenox on several occasions, leading to the medication being discontinued by a provider. Despite facility policy requiring notification of the resident's representative in such cases, there was no documented evidence that the representative was informed of either the refusals or the discontinuation of the medication. Further review of the resident's records showed that after the medication was discontinued, the resident experienced a medical event and was transported to the hospital, where they were diagnosed with an acute ischemic stroke. During the hospital admission, the resident's representative reported being unsure if the resident had been receiving the Lovenox injections at the facility. Interviews confirmed that the provider should have notified the representative about the medication change, but this did not occur.