Failure to Inform Resident and Representative of New Antihypertensive Medication
Penalty
Summary
A resident with a diagnosis including hypertension was admitted to the facility and subsequently prescribed amlodipine 5 mg daily for blood pressure control. Documentation in the resident's medical record, including progress notes and physician orders, confirmed the initiation and administration of amlodipine. However, there was no evidence that the resident or the resident's representative was informed in advance about the addition of amlodipine, its associated risks and benefits, or alternative treatment options prior to the medication being prescribed and administered. The manufacturer's insert for amlodipine lists several potential side effects, including headache, swelling, dizziness, and a potential risk of heart attack when first taking the medication. The deficiency was further substantiated by interviews with the resident, the resident's representative, and facility staff. The resident's family member, who serves as the emergency contact, expressed concern about the resident experiencing dizziness and was unaware of the new medication. Both the resident and the representative confirmed they had not been informed about the addition of amlodipine. Staff interviews revealed that the nurse responsible for administering the medication did not notify the resident or representative, and the Director of Nursing Services acknowledged that such notification was expected prior to starting the treatment.