Failure to Notify Responsible Party of Medication Changes
Penalty
Summary
Facility staff failed to notify a resident's responsible party regarding changes in the resident's medication regimen. The resident, who had diagnoses including metabolic encephalopathy, unspecified dementia with behavioral disturbances, anxiety disorder, depression, and altered mental status, experienced increased anxiety and restlessness. Following a psychiatric evaluation, Buspar was initially ordered and the caregiver was notified and authorized the medication. Subsequently, the resident continued to display agitation and aggression, leading to an increase in the Buspar dosage and the addition of Hydroxyzine for escalating anxiety and agitation. There was no documentation in the medical record that the responsible party was notified of the increase in the anti-anxiety medication or the addition of Hydroxyzine. The DON stated that the ADON verbally informed someone, but could not specify who was notified. A signed timeline indicating family notification was provided to the surveyor, but this documentation was created after the surveyor began investigating and was not present in the medical record at the time of the medication changes.