F0580

D

Failure to Notify Responsible Party of Multiple Medication Changes

Simsbury, Connecticut Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely notify the resident’s responsible parties of multiple medication changes following a loss of decisional capacity. The resident had diagnoses including pneumonitis, neuropathic bladder, and cognitive communication disorder, with an admission MDS showing a BIMS score of 9/15, indicating moderate cognitive impairment, dependence in ADLs, and an indwelling urinary catheter. The resident was initially self-responsible until 12/20/2025, after which two responsible parties were designated. The facility’s Change of Resident’s Condition policy required staff to notify the physician and family/representative of changes in condition and to clearly document the date, time, and persons notified in the nurse’s notes.

On multiple occasions in January 2026, the APRN and physician ordered new or revised medications for the resident, but the clinical record did not show that the responsible parties were notified. On 1/2/2026, the APRN assessed the resident for a sore throat and ordered Acetaminophen 325 mg, two tablets twice daily until 1/5/2026; there was no documentation that the responsible party was informed of this medication change. On 1/7/2026, after a follow-up visit for a non-improving sacral wound and pain, the APRN ordered Acetaminophen 500 mg, two tablets every eight hours for pain, again without documented notification to the responsible party. The APRN note that day also referenced the responsible party calling nursing to request pain medication prior to wound treatment, but there was still no record of notification regarding the new Acetaminophen order.

Further medication changes occurred later in the month without documented responsible party notification. On 1/12/2026, an APRN order directed Acetaminophen 325 mg, three tablets every eight hours for pain management, but the record did not show that the responsible party was notified of this new regimen, despite a nursing note documenting a family communication about labs and a catheter change. On 1/22/2026, after a nursing note described a new onset change in level of consciousness and brief non-responsiveness, the APRN was notified and physician orders were obtained for a urinalysis with culture, Doxycycline Hyclate 100 mg twice daily for seven days, and Acidophilus two capsules three times daily for seven days. Record review again failed to identify documentation that the responsible party was notified of these new antibiotic and probiotic orders. During interview, the DNS confirmed that responsible parties should be notified of new physician orders and that nurses on each shift were expected to notify and document, but could not provide documentation that this occurred for the medication changes on 1/2, 1/7, 1/12, and 1/22/2026.