Failure to Notify Representative of New Antipsychotic Medication
Penalty
Summary
The facility failed to notify a resident's representative when a new antipsychotic medication, Rexulti, was initiated. The resident, who had severe cognitive impairment, disorganized thinking, and inattention, was started on Rexulti for anxiety as documented in the physician's orders. Despite the resident's significant cognitive deficits and the presence of a responsible party who had signed the consent to treat form, there was no evidence in the progress notes that the responsible party was informed of the new medication. The facility's own Resident Rights form and care plan required notification and education of the resident or family regarding changes in care and treatment, including new medications. Interviews with family members revealed that they were not notified about the initiation of Rexulti and only became aware of the medication after noticing changes in the resident's behavior, such as increased grogginess and difficulty with speech. The DON stated an expectation that responsible parties should be notified of new medications, while the Administrator expressed uncertainty about the requirement to notify family members in the absence of a legal POA. The facility's failure to notify the resident's representative of the new medication constituted a deficiency in communication and adherence to resident rights.