Failure to Notify Resident Representative of Medication Change
Penalty
Summary
The facility failed to inform the resident representative (RR) of a change in the pain medication regimen for a resident who was totally dependent on staff for all activities of daily living and had diagnoses including right hip fracture, muscle weakness, seizures, and dementia. The resident's narcotic pain reliever was discontinued and replaced with Tylenol as needed, and subsequently, a new order for Robaxin, a muscle relaxant, was initiated on a routine basis. The RR, who was present in the facility most of the day, was not notified of the new Robaxin order and expressed concern that the medication made the resident drowsier, affecting participation in physical therapy. Interviews with facility staff confirmed that the order for Robaxin was written by an advanced registered nurse practitioner and entered into the medication administration record, but the RR was not informed of this change. The RR's lack of notification prevented them from making an informed decision regarding the resident's care needs, as required by regulation.