F0558

D

Failure to Notify Resident Representative of New Psychotropic Medication

Massillon, Ohio Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify the resident representative when a psychotropic medication was initiated for a resident. The resident, who had intact cognition per the admission MDS, had multiple diagnoses including cerebral infarction, COPD, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy, and vision loss, and had been sent to the emergency room during the stay. Health Care Power of Attorney (HCPOA) paperwork, dated and notarized on 08/11/25, identified a family member as the HCPOA, and this information was submitted to the facility. On 09/19/25, a physician ordered Remeron 7.5 mg at bedtime for decreased appetite, but there was no documentation that the resident’s representative was notified of this new psychotropic medication.

During interview, the HCPOA stated she was never informed that the resident was started on Remeron and believed that if he had decreased appetite, which she was never told about, it was likely related to pneumonia or a change in condition. The DON confirmed there was no documentation of the rationale for starting Remeron or of notification to the representative. The LPN who obtained the order reported she had observed the resident eating less than 50% of meals over a couple of days, did not want him to lose weight, and therefore called the physician for the Remeron order instead of consulting the dietitian, who was not present that day. She stated she had tried protein shakes from her medication cart, which the resident did not like, and that no other supplements were ordered. The LPN reported she was sure she had informed the emergency contacts about the Remeron but acknowledged she failed to chart this, and there was no documented evidence of notification in the record.