Failure to Notify Resident Representatives of Medication Changes
Penalty
Summary
The facility failed to notify resident representatives of medication changes for two residents. For one resident with diagnoses including type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia, there was no documentation that the resident's representative was informed when a new order for metformin was initiated. The resident had impaired cognition, and the lack of notification was confirmed by the Director of Nursing (DON) during an interview. For another resident with chronic obstructive pulmonary disease, hypertension, dementia, osteoarthritis, and GERD, there was no documentation that the resident's representative was notified when a therapeutic interchange was made from lansoprazole to omeprazole for GERD management. The resident had intact cognition, and the DON confirmed that the representative should have been notified of the medication change. Review of the facility's policy indicated that responsible parties should be notified of changes in the resident's condition or status.