Failure to Honor POA Request to Hold Medication
Penalty
Summary
The facility failed to honor a resident's power-of-attorney (POA) request to hold Depakote, a mood stabilizer, resulting in the medication being administered despite explicit instructions from the POA. The resident, who had diagnoses including ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive, was admitted with a POA who specifically requested that no medications with a black box warning be given. The POA communicated this request to staff and expected it to be addressed by the provider. However, a new order for Depakote was written and the medication was administered multiple times over several days. Interviews revealed that the POA had informed staff not to administer Depakote until she could speak with the psychiatric doctor, but the medication was still given. Nursing staff were not all aware of the request to hold the medication, and some believed the resident needed it. Communication about the POA's request was not effectively documented or relayed, as some nurses did not check the communication book or see the note to hold Depakote. The deficiency was identified during a complaint investigation.