Failure to Notify Responsible Party of New Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a new medication order. The resident was admitted with multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction, bipolar II disorder, type 2 diabetes mellitus, schizoaffective disorder bipolar type, generalized anxiety disorder, unspecified convulsions, unspecified conjunctivitis, a left hip contracture, and a sacral pressure ulcer. The resident’s MDS showed a BIMS score of 9, indicating moderately impaired cognition. In June 2025, the physician ordered Depakote 125 mg by mouth twice daily for mood stabilization related to schizoaffective disorder, bipolar type, with a start date of 06/30/2025, and the June 2025 MAR documented that Depakote administration began on that date. During a telephone interview, the resident’s responsible party reported she was not notified when Depakote was started and only became aware of the medication on 07/24/2025 when the resident refused a blood draw for a Depakote level. Review of the resident’s medical record, including progress notes, did not reveal any documentation that the responsible party had been informed of the initiation of Depakote in June 2025. In an interview, the DON confirmed that the responsible party should have been notified of the Depakote order and acknowledged she could not provide any evidence that such notification occurred.
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