F0580

D

Failure to Notify Health Care Agent of Antidepressant Dose Reduction

Taunton, Massachusetts Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly notify an activated Health Care Proxy (HCP)/Health Care Agent (HCA) of a significant change in a resident’s antidepressant medication dosage. Facility policy on Change in Resident Condition, revised December 2025, required licensed nursing staff to timely notify the responsible party/next of kin or resident representative when there is a need to alter treatment significantly, and to document all changes and notifications in the medical record. Resident #1 had an invoked HCP as of April 15, 2020, and the Advanced Directives Care Plan indicated that the family would be contacted as necessary to keep them updated on any changes in condition.

Resident #1 was admitted in March 2020 with multiple diagnoses including Alzheimer’s disease, recurrent major depressive disorder, anxiety disorder, COPD, osteoarthritis, carotid artery occlusion/stenosis, bullous disorder, cellulitis of both lower limbs, and a non-displaced intertrochanteric fracture of the left femur. A consultant pharmacist’s recommendation dated 09/30/25 noted that Resident #1 was receiving Sertraline 100 mg daily and recommended periodic dose evaluation and a gradual dose reduction (GDR) to determine the lowest effective dose, unless clinically contraindicated. The Nurse Practitioner (NP) agreed with the recommendation, wrote a new order to decrease Sertraline from 100 mg to 75 mg daily on 10/03/25, and documented on the pharmacist recommendation form that it was unlikely the HCA would agree with the GDR. The NP later stated she agreed with the dose reduction pending the HCA’s approval and expected nursing to notify the HCA and obtain approval before implementing the new order.

On 10/03/25, Nurse Supervisor #2 transcribed the NP’s order for Sertraline 75 mg into the electronic medical record and reported that she assumed the NP had already discussed the dose reduction with the HCA and obtained approval. Resident #1’s Medication Administration Record shows that from 10/04/25 through 11/21/25, the resident received Sertraline 75 mg daily. There was no documentation in the medical record that the HCA was notified of the dose reduction. During a later care plan meeting, the HCA reported learning at that time that the antidepressant dose had been decreased the previous month and stated that, as the HCA, she had requested that the dosage not be changed and expected to be notified of any medication changes. The DON confirmed that Resident #1 had an invoked HCP and that the Nursing Supervisor transcribed the order to decrease Sertraline without notifying the HCA of the new dosage recommendation, contrary to the DON’s expectation that nursing notify the HCA of any medication dosage changes prior to implementation.