Failure to Notify Resident Representative of Significant Medication Discontinuations
Penalty
Summary
The deficiency involves the facility’s failure to immediately inform a resident’s representative when there was a significant alteration in treatment, specifically the discontinuation of multiple medications. An elderly male resident with severe cognitive impairment, metabolic encephalopathy, type 2 diabetes mellitus, altered mental status, unspecified dementia, and acute and chronic respiratory failure with hypoxia was admitted with multiple active care plans addressing cardiovascular status, renal status, pneumonia, diabetes, fluid balance, and antidepressant use. His admission MDS showed a BIMS score of 3, indicating severe cognitive impairment, and his MPOA identified a family member as the resident’s representative. On a documented physician visit, the MD’s initial H&P noted that the resident was a poor historian, alert and oriented x0, not eating or drinking, and refusing medications. The MD assessed presumed chronic diagnoses with acute delirium of unknown etiology and determined that the delirium could be related to medications, decreased oral intake, or dehydration. As part of the plan, the MD decided to minimize medications and discontinue several drugs, including Xanax (alprazolam), Depakote (divalproex sodium), mirtazapine, Lasix (furosemide), and potassium chloride. Review of the MAR confirmed that, around this time, orders for amoxicillin-potassium clavulanate, alprazolam, divalproex sodium, mirtazapine, furosemide, eplerenone, glipizide, and potassium chloride were discontinued. Interviews and record review showed that the resident’s family member, who was the MPOA, was not notified when these medications were discontinued. The family member reported not being informed of the medication changes and only learned that the resident was no longer receiving antidepressant or mood stabilizer medications after specifically asking about alprazolam several days later. Nursing staff and leadership (LVNs, DON, and ADM) stated that it was the nurse’s responsibility to notify the resident or POA of medication changes and that family should be notified of any medication changes, change in condition, or refusals. The MD stated he did not personally contact the POA or family unless requested and relied on nursing staff to notify them of changes. Facility in-service records and the written policy on change in condition indicated that residents or their representatives were to be notified of changes in condition and in medical or nursing care, but this did not occur for this resident when the medications were significantly altered.
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