Failure to Notify Resident Representative of New Medication Orders
Penalty
Summary
The facility failed to notify a resident's representative of new medication orders, as required by policy. A resident with severe cognitive impairment, Alzheimer's disease, and major depressive disorder with psychotic symptoms had changes to her medication regimen, including an increase in Risperdal dosage and the addition of vitamin D3. Documentation in the resident's record did not show that the representative was informed of these new orders. Progress notes specifically lacked evidence of notification following both the Risperdal dosage change and the initiation of vitamin D3. Interviews with the resident's family member revealed ongoing issues with communication from the facility regarding changes in the resident's care. The DON confirmed, after reviewing the 24-hour report and medical record, that there was no documentation of notification to the resident's representative for the medication changes. Facility policy requires that residents and their representatives be informed of changes in health status and treatment, but this was not followed in these instances.