Failure to Involve Residents in Medication Changes and Care Planning
Penalty
Summary
The facility failed to ensure that four cognitively intact residents were informed in advance and allowed to participate in changes to their person-centered plan of care, specifically regarding medication adjustments. Multiple residents reported that their medications, including psychotropic and pain medications, were changed or discontinued without prior discussion or notification. Interviews revealed that residents only became aware of these changes after experiencing symptoms or upon inquiry, rather than through proactive communication from staff. Documentation in the medical records did not show evidence that residents were involved in or informed about these medication changes. For example, one resident with a history of major depressive disorder, anxiety, and bipolar disorder was not informed about the gradual dose reduction and discontinuation of several psychotropic medications, including Clonazepam and Seroquel. The resident only learned of the changes after noticing symptoms and speaking to nursing staff. Another resident with severe depression and anxiety experienced a reduction in Clonazepam dosage without prior notification, resulting in emotional distress. Similarly, a resident with chronic pain and anxiety had multiple medication changes, including the discontinuation and re-initiation of pain medications, without being consulted or informed about the reasons for these changes. Staff interviews confirmed that there was no consistent process for documenting or ensuring resident involvement in medication changes. The facility's own policies required notification of residents and their representatives when significant changes to treatment occurred, but these procedures were not followed. The lack of communication and documentation was acknowledged by facility leadership, who noted that the forms used for psychiatry notes did not include a section for resident notification or involvement in care planning.