Failure to Inform Resident of New Medication Orders and Associated Risks
Penalty
Summary
Facility staff failed to notify a cognitively intact resident of new physician orders for the administration of Percocet and Xanax, including the associated risks, benefits, and alternatives. The resident, who had diagnoses including cancer of the larynx and anxiety, was admitted with a PEG tube and was capable of making daily decisions as indicated by a high BIMS score. Despite physician orders for these controlled medications and documented administration on multiple occasions, there was no evidence that the resident was informed in advance about the medications or their potential effects. The resident's care plan included an intervention to educate the resident and their family or caregivers about the risks, benefits, and side effects of medications being given. However, interviews with facility staff confirmed that no documentation or evidence existed to show that this education or notification occurred prior to the administration of Percocet and Xanax. The facility's policy requires residents to be informed and participate in care planning and treatment, but this was not followed in this instance.