F0580

D

Failure to Timely Notify Physician of Ongoing Psychotropic Medication Refusals

Los Angeles, California Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely notify a resident’s physician of ongoing refusals of a prescribed psychotropic medication, Depakote, ordered for paranoid schizophrenia. The resident was admitted with diagnoses including paranoid schizophrenia, psychosis, and muscle weakness, and had a physician’s order for Depakote 125 mg twice daily for schizophrenia. The resident’s care plan, initiated and later revised, documented use of Depakote for paranoid schizophrenia, with interventions to assess daily for behaviors, notify the physician if the medication could be reduced, and monitor and report behaviors monthly to the physician/psychiatrist. The MDS indicated the resident was cognitively intact and required set-up assistance with ADLs.

Review of the MAR for January showed the resident repeatedly refused Depakote at scheduled 9 a.m. and 5 p.m. doses on numerous days throughout the month, including multiple consecutive refusals. Facility staff, including an LVN, stated that when the resident refused medications, they would offer them twice and that the physician should be notified when refusals occurred. The RN supervisor acknowledged the resident had been refusing Depakote and that the medication was for control of delusions. The DON stated that refusal of Depakote would exacerbate the resident’s condition and confirmed there was no documentation that the primary physician or psychiatrist had been notified of the refusals prior to a change-of-condition note created on January 30, when the physician was finally notified. The facility’s policy on change in condition required physician notification when a resident refused treatment or medications two or more consecutive times, which was not followed in this case.