Failure to Notify Resident of Medication Change
Penalty
Summary
The facility failed to notify a resident about a significant change in their medication regimen. Specifically, the resident, who had diagnoses including heart failure and impaired kidney function and was cognitively intact, was not informed that their prescribed Potassium Chloride supplement was placed on hold for thirteen days. The medication was held due to abnormal laboratory results and impaired kidney function, as determined by the primary care physician. Despite this change, there was no documentation or evidence that the resident was notified about the medication being stopped or the reason for the change. Interviews with facility staff, including an LPN/Resident Care Manager, a Registered Nurse, and the Director of Nursing Services, confirmed that residents are supposed to be notified of all medication changes. However, staff were unable to identify any record of notification to the resident regarding the hold on Potassium Chloride. The resident also stated they were unaware of the medication being stopped or restarted and had not been informed by facility staff.