Failure to Notify Resident Representative of Parkinson’s Medication Change
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant medication change as directed by the resident’s care plan. The resident, who had a diagnosis of Parkinson’s disease and an active order for carbidopa-levodopa 25/100 mg, two tablets by mouth four times daily, had a comprehensive care plan dated 02/28/24 instructing staff to notify the resident’s son of medication changes and behaviors. Nursing progress notes documented that on 11/10/2025 staff placed the resident’s carbidopa-levodopa on hold for seven days to assess for improvement in behaviors, and on 11/11/2025 the resident developed weakness and upper extremity shaking after the medication was held, leading the physician to order the medication at a reduced dose of 0.5 mg four times daily due to worsening symptoms. The record also showed that during a later meeting, the resident’s son expressed concerns that he had not been informed of the recent change to the Parkinson’s medication and the side effects that occurred after it was discontinued. In interviews, the resident stated he was unaware that the facility had stopped administering his carbidopa-levodopa until his hands began to shake aggressively, which bothered him. The resident’s son, identified as the resident’s POA, reported that the facility stopped the Parkinson’s medication, which had been given four times daily, and that he only learned of the discontinuation afterward, prompting him to contact the facility to ask why it had been stopped. He stated staff told him the medication was stopped to see if this would improve the resident’s behaviors and confirmed that the facility knew they were to notify him prior to any medication changes, but he was not contacted about the carbidopa-levodopa being stopped. The Administrator acknowledged that, because the care plan directed staff to notify the son regarding medication changes or behaviors, staff should have notified him prior to any changes and confirmed that the son was not notified before the Parkinson’s medication management was altered.
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