Failure to Notify Resident and Legal Representative of Medication Change
Penalty
Summary
The facility failed to notify a resident and the resident's legal representative of a medication change. The resident, who had a power of attorney appointing his wife as his legal representative and responsible party, was prescribed cyclobenzaprine, a muscle relaxer, on admission. The order was later revised to a 14-day duration. There was no documentation in the clinical record indicating that either the resident or his legal representative was informed of the initial medication order or the subsequent change. Staff interviews confirmed that the process for new medication orders requires nurses to inform the resident and, if applicable, the responsible party. The unit manager and DON both acknowledged that there was no evidence in the electronic health record that the resident or his responsible party were notified about the cyclobenzaprine order. Review of facility policies revealed that existing policies did not specifically address notification requirements for new or changed physician orders unless there was a significant change in condition.