Failure to Notify Resident Representative of New Psychotropic Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s health care power of attorney (HCPOA) when a new psychotropic medication was ordered. The resident, who had intact cognition, was admitted with 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 on a prior date. HCPOA paperwork naming a family member as the resident’s representative had been completed and submitted to the facility. On a documented date, the 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 order. During interview, the HCPOA stated she was never informed that Remeron had been started and believed the medication would have been used to sedate the resident rather than for appetite, noting she had not been told of any appetite issues and believed any decreased intake would likely be 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. The LPN stated she had attempted to offer protein shakes from her cart, which the resident did not like, and that she believed she had informed the resident’s emergency contacts about the Remeron but acknowledged she failed to chart any such notification. This lack of documented notification to the resident’s representative regarding initiation of a psychotropic medication constituted the cited deficiency.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.