Failure to Notify Responsible Party of Medication Change and Lack of Psychiatric Evaluation
Penalty
Summary
The facility failed to notify the responsible party of a change in medication and did not provide a psychiatric evaluation for one resident. According to the facility's policy, notification is required when there is a need to alter treatment, including new treatments or discontinuation of current treatments. Review of the electronic medical record showed that the resident had diagnoses including generalized anxiety disorder, dementia, psychotic disturbance, mood disturbance, anxiety, and delirium. Physician orders indicated a medication was reordered at a lower dose after consultation with the family to increase the dose, but there was no documentation that the responsible party was informed when the medication was discontinued or when a psychiatric consultation was not provided. A telephone interview with the resident's family member revealed confusion and concern about not being informed that the resident was no longer receiving the medication or a psychiatric consultation, resulting in the resident being without the medication for nearly three weeks. This led to increased anxiety and depression and ultimately the resident being sent to the hospital. Interviews with facility staff, including the nurse practitioner and the DON, confirmed that follow-up on the order and adherence to physician orders were not completed as required.