Failure to Notify Resident Representative of New Antihypertensive Medication
Penalty
Summary
The facility failed to notify a cognitively impaired resident’s health care power of attorney (POA) prior to initiating a new antihypertensive medication. The resident’s care plan dated 6/6/25 documented cognitive impairment related to dementia and multiple sclerosis, noted that she was very forgetful, and directed that all information be provided directly to her advocate. A POA form dated 9/12/24 identified a family member (V7) as the resident’s POA. Physician progress notes and a physician order dated 8/8/25 showed the resident was started on Losartan 25 mg daily for a new diagnosis of hypertension, and the physician documented that the new medication was discussed with the resident. However, there was no documentation that the POA was notified of the resident’s elevated blood pressures or the initiation of Losartan. On interview, the POA stated she was not informed that the resident had high blood pressure or that Losartan had been started until she spoke with a cardiology nurse practitioner on 12/17/25, despite being in the facility at least twice a week and having repeatedly requested to be notified of any changes, including medications. A cardiology note dated 12/17/25 confirmed that the nurse practitioner contacted the POA, who reported she was unaware the resident was taking Losartan. During observation on 1/5/26, the resident was awake but confused to place and time, unable to state the month, and did not know if she was on a medication for high blood pressure, stating that staff talk to her family member about all her medications. Social services staff described the resident as confused and forgetful with impaired short-term memory and confirmed that the POA was very involved and had requested to be informed of any changes. The DON stated that when a resident is started on a new medication, the resident and/or representative should receive education and consent prior to administration, and acknowledged that the cognitively impaired resident’s representative, who had requested notification of all changes, was not notified prior to starting Losartan.
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