Failure to Document Change of Condition Assessment After Medication Refusal
Penalty
Summary
The facility failed to document a change of condition (COC) assessment for a resident who refused psychotropic medications. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and epilepsy, was noted to have severe cognitive impairment and required assistance with activities of daily living. Despite the resident's repeated refusal of medications on multiple occasions, the licensed vocational nurse (LVN) only documented the refusal but did not complete a COC assessment as required by facility policy. The LVN acknowledged that medication refusal constituted a change in condition and should have been documented accordingly. Interviews with the resident confirmed ongoing refusal of medications, and the Director of Nursing (DON) verified that no COC assessment was completed in response to these refusals. Facility policy required licensed nurses to assess changes in condition, determine appropriate interventions, and notify the resident's physician and legal representative or family member in the event of untoward responses to medications. The lack of a documented COC assessment meant that the resident's current condition and behavior were not properly monitored as per policy.