F0552

D

Failure to Inform Resident Representative of Pain and Psychotropic Medication Changes

Napa, California Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to inform a resident’s family member of significant changes to the resident’s treatment plan for pain and behaviors, despite the resident lacking capacity to make healthcare decisions. The family member reported receiving a call that the resident was in respiratory distress after an increase in her fentanyl patch dose to 50 mcg/hr, and stated that he would not have agreed to this increase because the resident was already on multiple central nervous system depressants. He also reported that the resident’s Seroquel dose had been doubled in the hospital and continued upon her return to the facility without any discussion with him, even though the resident had delirium and was not at her baseline during the hospitalization. The family member described finding the resident slumped over in a chair and slurring her words, and later learned via text communication with the physician that there was also a PRN Seroquel order that he had not been informed about.

Record review showed that the resident had multiple diagnoses including dementia with behavioral disturbance, epilepsy, chronic pain, traumatic brain injury, bipolar disorder, anxiety disorder, and cerebral infarction. The face sheet listed the resident as her own responsible party, but the medical director had previously informed surveyors that the resident did not have capacity to make healthcare decisions and confirmed that this had not changed and no county conservator had been arranged. Physician orders and MARs showed a fentanyl patch 25 mcg/hr ordered in November and discontinued in late January, with a new order for a fentanyl patch 50 mcg/hr dated 1/30 and administered on 1/30, as well as Seroquel 25 mg three times daily for agitation and later Seroquel 50 mg three times daily with an added PRN Seroquel 25 mg every six hours for agitation. Nursing progress notes documented discontinuation of the 25 mcg patch and initiation of the 50 mcg patch but contained no documentation that the family member was notified of this change.

Interviews with facility staff confirmed the lack of family notification and informed consent. One licensed nurse stated that the family member was not informed of the decision to increase the fentanyl patch at the end of January. Another licensed nurse verified there was no informed consent signed for the increased Seroquel dose or the PRN Seroquel order and acknowledged that a new consent should have been obtained when the dose was increased and a PRN dose added in the hospital. The medical director confirmed that the resident still lacked decision-making capacity and stated that residents’ families have the right to participate in the plan of care and that he expected nursing staff to have informed the family member of the fentanyl dose increase. Facility policies on resident rights, psychotropic medication use, and comprehensive person-centered care planning required resident or representative participation in treatment decisions and care planning, informed consent for psychotropic medication changes, and documentation when resident or representative participation in care planning was not practicable, which did not occur in this case.