Failure to Notify Resident Representative of New Psychotropic Medication
Penalty
Summary
The facility failed to notify a resident’s representative of a newly prescribed medication. An undated admission record for Resident #2 identified a family member as power of attorney, responsible party, and primary emergency contact. An annual assessment dated 10/18/25 documented that the resident had non-Alzheimer’s dementia and senile degeneration of the brain, was severely cognitively impaired, and was dependent on staff for all activities of daily living. A nurse practitioner’s progress note dated 11/20/25 showed that sertraline 25 mg once daily was prescribed for mood, and a nurse’s progress note dated 11/21/25 documented that the resident continued on sertraline with no adverse reactions. However, there was no documentation that the resident’s representative had been informed of the new medication order, and the DON stated that the nurse who took the order had not reached out to the representative, as it was not documented.
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