F0580

D

Failure to Notify Responsible Party of Resident’s Medication Changes

Coupeville, Washington Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The facility failed to notify a resident’s responsible party of new and changed medication orders, as required, for one of three sampled residents reviewed for notification of changes. The resident had dementia with anxiety and was documented on an MDS assessment dated 12/30/2025 as having severe cognitive impairment. A physician order dated 01/21/2026 directed an increase in the resident’s acetaminophen to two tablets every 12 hours and initiation of a daily lidocaine patch to the lower back for back pain, to be removed per schedule. Review of the electronic medical record showed no documentation that the responsible party (Collateral Contact 1) had been notified of the resident’s back pain or these medication changes. During a telephone interview, the responsible party reported they were not kept informed when the resident had changes in medications, and during staff interviews, leadership staff stated that responsible parties are to be notified of medication changes, despite the lack of notification in this case.

This failure prevented the person responsible for making healthcare decisions from being part of the care planning process and from being knowledgeable about the medications the resident was taking, in violation of WAC 388-97-0320(1)(c).