Failure to Notify Resident and Family of Medication Changes and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to follow its own notification of changes policies by not informing a cognitively intact resident and/or the resident’s representatives of multiple medication changes and a hospital transfer. The facility’s policies required that changes in a resident’s condition or treatment be immediately shared with the resident and/or resident representative, that non-immediate changes be communicated on the shift they occurred, and that residents/representatives be educated about risks and benefits to allow informed choice. The resident’s face sheet showed the resident was his/her own responsible party, with two emergency contacts listed, and the admission MDS documented the resident as cognitively intact. Record review showed several physician order changes for colchicine and methotrexate that were not accompanied by documented notification to the resident or emergency contacts. Colchicine 0.6 mg twice daily was ordered on 10/15/25, held on 10/17/25, resumed on 10/20/25, changed to once daily on 10/24/25, and then discontinued on 10/25/25. Nurse notes contained no documentation that the resident or emergency contacts were notified when colchicine was restarted or when the directions changed. Methotrexate 2.5 mg was initially ordered as needed for rheumatoid arthritis flare-ups and later changed on 12/5/25 to a scheduled daily dose, again with no documentation in nurse notes that the resident or emergency contacts were notified of this change. The facility also failed to document notification of the resident’s emergency contacts when the resident was transferred to the hospital for abnormal vital signs on 1/14/26. The transfer form showed the resident was sent to the hospital by ambulance, but nurse notes contained no record of family notification. During interviews, both listed emergency contacts reported they were not informed of the medication changes or the hospital transfer, and one stated the family only learned of the hospital visit when a friend saw the resident entering the emergency department. An LPN stated nurses were supposed to call families for hospital transfers and significant changes, and the DON stated her expectation was that family would be notified when a resident was sent to the emergency department, but also indicated staff did not consider family notification required for medication changes when the resident was his/her own responsible party unless the family had requested it.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.