Failure to Notify Resident Representative of Pain Medication Change
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to have their designated representative informed of significant changes in care, specifically a change in prescribed pain medication. Resident 1, who lacked decision-making capacity and had her daughter designated as responsible party, was admitted with multiple serious medical conditions including chronic respiratory failure with hypoxia, tracheostomy, gastrostomy, ventilator dependence, hemiplegia, hemiparesis, and vascular dementia. On one date, a physician made rounds while the responsible party was at the bedside and, at the responsible party’s request for pain management, ordered Tylenol #3 (acetaminophen-codeine) for pain. This order was faxed to the pharmacy. The pharmacy notified the RN that Tylenol #3 was not recommended due to the resident’s documented allergy to hydrocodone. The RN then contacted the physician, who changed the order from Tylenol #3 to tramadol 50 mg via G-tube every 12 hours as needed for moderate to severe pain. The RN acknowledged that the responsible party was not notified of this change in medication from Tylenol #3 to tramadol, despite the facility’s process and policy requiring that resident representatives be informed of changes in condition, care, and services, and the policy on patient rights stating that patients and their designated representatives have the right to participate in decisions regarding care and to receive information necessary for informed consent or refusal.
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