Failure to Notify Family of Significant End-of-Life Condition and Medication Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family representative of significant changes in the resident’s condition, treatment, and medication regimen, as required by facility policy and 10NYCRR 415.3. The facility’s written policy on Change in Resident Status Notification required that the attending physician and responsible party be notified when there is a significant change in the resident’s physical, mental, or psychosocial status, or when there is any situation requiring a change in the plan of care, medications, or treatment regimen. Surveyors reviewed the medical record of a resident with dementia, cerebral infarction, and heart failure, whose MDS documented severely impaired cognition, and found no documented evidence that the family representative was notified of multiple significant changes in condition and pain management. From the dates reviewed, the resident’s pain management regimen changed several times. Initially, the resident was prescribed tramadol 50 mg by mouth every morning and at bedtime for pain, and oxycodone 5 mg by mouth every six hours as needed for pain. Subsequently, the resident was prescribed morphine sulfate 5 mg every six hours as needed for pain, shortness of breath, and restlessness related to end-of-life hospice care, and later morphine sulfate 10 mg buccally every three hours as needed for the same indications. Additional orders included initiation of 2 liters of oxygen via nasal cannula for low oxygen levels and an acetaminophen 650 mg suppository for fever. A nursing progress note documented a call from a hospice nurse reporting increased pain and discussing the resident’s pain regimen, with a plan to follow up with the nurse practitioner, but there was no documentation that the family representative was notified of the increased pain or the potential changes in pain management at that time. The record further showed that the resident’s family representative only received information about the increased morphine dosage after they themselves contacted the facility for an update, at which time they were informed of the dosage increase to address increased pain. The resident later expired, with the time of death documented in the nursing notes. In interviews, the complainant stated they were not notified when morphine was started and were unaware of its use until they called the facility, at which point they were told the resident had been declining for about a week and that medication changes had been made. The nurse practitioner stated that changes such as increasing morphine from 5 mg to 10 mg represent a significant change requiring family notification. The LPN Unit Manager and the Director of Nursing both acknowledged that staff are expected to notify family representatives of significant changes and to document such notifications, and upon review of the progress notes, they were unable to find documentation that the family representative had been notified of the medication and condition changes.
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