F0580

D

Failure to Notify Resident Representative of New Narcotic Pain Medication Order

Dallas, Texas Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to notify a resident’s designated Resident Representative (RR) of a significant change in treatment. A male resident with dementia and depression, admitted in mid-2025 and assessed as having intact cognition on a quarterly MDS, had an order for Tramadol HCl 50 mg by mouth every 8 hours as needed for pain, prescribed in late 2025. The resident’s admission forms, signed earlier in 2025, showed that the RR had consented to the resident receiving treatment at the facility. However, record review and interviews revealed that the RR was not notified when Tramadol, a narcotic pain medication, was prescribed. The RR reported she was unaware the resident was receiving Tramadol and believed she should have been informed of the physician’s orders, particularly because the resident was a recovering alcoholic.

During interviews, the RR stated she had spoken with the Administrator, who told her the facility did not have to contact the RR because the resident was of sound mind. The Administrator and Chief Nursing Operator confirmed they believed that, since the resident was coherent and able to make his own decisions, the RR did not need to be notified of the new medication order and that the RR would only be contacted if the resident was not coherent. The DON and ADON stated they were unsure whether consent from the RR was required when a resident was of sound mind, but indicated they generally tried to keep the RR informed because she was frequently in communication with nursing staff. Review of the facility’s Resident Representative policy defined the RR as an individual chosen by the resident to act on the resident’s behalf in decision-making and to receive notifications, but the RR was not notified of the Tramadol order as required.