Failure to Involve Resident in Medication and Treatment Decisions
Penalty
Summary
The facility failed to ensure that a resident was informed of and able to participate in treatment decisions regarding significant changes to his medication regimen. The resident, who had chronic pain syndrome and a history of polysubstance abuse, was admitted with an established methadone prescription managed by an external methadone clinic. Upon admission, the facility staff initiated changes to the resident's methadone dosage and considered transitioning him to Suboxone without adequately informing the resident or involving him in the decision-making process. Documentation did not reflect that the risks, benefits, or alternatives to these changes were discussed with the resident, nor that he agreed to the modifications. The resident's care plans and progress notes lacked evidence that his chronic pain and substance use disorder were being managed in coordination with his methadone clinic. The methadone clinic was not notified of the resident's placement at the facility, resulting in a lack of communication regarding medication management. The resident expressed confusion and distress about the changes to his methadone dosing, indicating he did not understand the reasons for the adjustments, especially given his long-term use and established care with the methadone clinic. Staff interviews confirmed that documentation of resident involvement and informed consent for medication changes was insufficient or absent. Facility policy states that residents have the right to be informed about their medical condition and prescriptions, to participate in decisions affecting their care, and to be involved in developing their care plan. Despite this, the resident was not included in key care conferences or medication decisions, and the methadone clinic responsible for his ongoing treatment was not consulted or informed in a timely manner. This resulted in the resident not receiving his usual dosage and being excluded from decisions about his care.