Failure to Notify Resident Representatives of Death and Medication Changes
Penalty
Summary
The facility failed to notify a resident's legal representative of the resident's death and failed to notify another resident's representative of a new medication order. In the first case, the legal representative of a resident who passed away was not successfully contacted by the facility, despite multiple documented attempts to reach her by phone. The legal representative reported not receiving any calls or voicemails from the facility and only learned of the resident's death when contacted by the funeral home. Documentation in the medical record showed that the nurse attempted to call both listed phone numbers but was unable to reach the representative. The facility's policy required that the family or representative be informed of a resident's death, but there was no evidence that successful notification occurred. In addition, the facility did not notify the medical power of attorney (MPOA) for another resident when a new medication, Vistaril, was ordered for anxiety following a psychiatric evaluation. The record review confirmed that the MPOA was not informed of the medication change, and there was no documentation of a change in condition or notification. During an interview, the MPOA stated they were unaware of any anxiety issues and had not been notified about the new medication order. Both deficiencies were identified through record review, policy review, and interviews with resident representatives and staff. The facility's own policies outlined the requirement to notify resident representatives of significant changes, including death and new medication orders, but these procedures were not followed in the cases reviewed.