Failure to Notify Responsible Party of Medication Change
Penalty
Summary
The facility failed to follow its policy and procedures regarding resident rights by not informing the responsible party (RP) or power of attorney (POA) about a change in a resident's medication dosage. The resident in question had severe cognitive impairment and multiple diagnoses, including dementia, muscle weakness, dysphagia, hyperlipidemia, and hypothyroidism. The resident was admitted with a designated RP/POA due to their inability to make decisions independently. A review of the resident's records showed that the dosage of Donepezil, a medication used to treat dementia symptoms, was decreased from 15 mg to 10 mg per day by the physician. Despite this significant change in medication, there was no documentation in the nursing or physician progress notes indicating that the RP/POA was notified of the change. The Director of Staff Development confirmed during an interview and record review that there was no evidence of notification and acknowledged that such changes should be reported to the responsible party, as it is their right to know. The facility's policy on resident rights, revised in January 2025, states that residents and their legal representatives must be informed of any changes in medical condition or treatment, which was not followed in this instance.