Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
Guardian Not Informed of Antipsychotic Dose Increase: A resident with schizophrenia and dementia had Haldol increased from 1 mg BID to 2 mg AM and 3 mg HS, but the record lacked documentation that the court-appointed guardian was informed or that guardian consent was obtained for the psychotropic dose change. The DON stated the guardian should have been notified and signed the consent, while the consent form in the record was signed by the resident.
A resident with Alzheimer’s disease, dementia, and anxiety was started on Valium and later buspirone for anxiety, agitation, and irritability, with multiple changes in dosing and frequency, without any signed informed consent documented in the clinical record. The resident’s spouse reported she was not asked to sign an informed consent and only received information about the medication from the pharmacy when picking it up. The Social Service Director stated that informed consents were required for all psychotropic medications but did not recognize buspirone as requiring consent due to the absence of a black box icon in their system and relied on nursing staff to notify her of dose changes. Despite a facility policy requiring documentation of discussions about risks and benefits of psychoactive medications, no such documentation or signed consents were present for these medications.
A resident with bipolar disorder, anxiety, and mild cognitive impairment, documented as cognitively intact and independent with ADLs, was transferred under an Emergency Detention Order to a psychiatric facility after refusing to go and being escorted by police. Facility staff reported to the psychiatric facility that the resident had recent physical and verbal aggression, including cursing at a roommate and spraying a staff member with chemicals, but these behaviors and alleged medication refusals were not supported by nursing documentation in the clinical record and were based on secondhand reports from social services. The DON later stated the resident had not shown aggressive behaviors, there was no documented medication refusal, and she was unsure why the resident was sent to a psychiatric hospital, while the resident reported she did not understand why she was transferred and that the reason was never explained to her, demonstrating a failure to ensure the resident was fully informed of and able to choose her treatment.
The facility failed to keep residents and their representatives informed about key aspects of care and treatment. A resident with a recent above-knee amputation and chronic pain had a prescribed narcotic pain medication dose reduced without being informed, only discovering the change when the medication appeared different, and there was no documentation of notification in the record. The same resident had a hospital-ordered vascular follow-up appointment for suture management that was missed, with no documented effort by the facility to notify the resident of the appointment or to reschedule after a no call/no show. In a separate case, another resident with dementia was discharged from therapy after about a month when max potential was deemed reached, but the PT did not notify the family and relied on nursing staff, and the record contained no documentation that the resident’s representative was informed of the discontinuation of therapy.
A resident with dementia and multiple comorbidities remained on a full liquid diet carried over from a hospital stay, even though the liquid diet had been ordered for nutritional reasons rather than swallowing issues and the resident was observed eating without difficulty. The resident’s POA and family repeatedly requested a change to a soft/mechanical diet, reporting they had safely fed the resident soft foods such as mashed potatoes and cottage cheese, but facility staff stated they would not change the order and discussed requiring a legal waiver if the family fed foods outside the ordered diet. Therapy and nursing leadership indicated that, because the resident could not follow commands, they believed she did not meet criteria for a diet change and did not ensure a timely, thorough swallow evaluation, resulting in the facility not honoring the resident representative’s diet preferences despite a policy supporting resident self-determination.
A resident with COPD, heart failure, dementia, and other conditions, who was on oxygen therapy, developed a cough and later received a new order for albuterol nebulizer treatments twice daily for the cough. The medical record lacked documentation that the resident’s representative was informed of this change in condition and new medication order. In interview, an LPN confirmed she did not document any communication with the representative, and the DON stated that such communication and documentation should have occurred.
A resident with end stage renal disease and psychiatric diagnoses, but documented intact cognition, was moved to a secured memory care unit and had his cell phone removed from his possession without his consent or documented discussion with him. He reported that after independently going outside to the front porch, staff later placed a monitor on him, moved him to the secured unit, and took his phone, leaving him feeling like a prisoner and unsure why he was on the unit. Facility records showed that the IDT and Social Services discussed exit seeking and impulsive or manic behaviors with the resident’s family, who agreed to the room change and phone restriction, but behavior logs did not document exit seeking or related behaviors during the reviewed period, and there was no documentation that the resident himself was informed of or involved in these decisions, despite a policy affirming residents’ rights to dignity and respect.
A resident with chronic pain syndrome and a history of substance use disorder did not receive adequate information or involvement in decisions regarding changes to his methadone regimen. Facility staff altered the resident's methadone dosage and considered transitioning to Suboxone without proper documentation of informed consent or discussion of risks, benefits, and alternatives. The resident's methadone clinic was not notified of his admission, leading to confusion and distress for the resident, and the facility failed to ensure the resident's participation in care planning as required by policy.
A resident recovering from knee replacement surgery was not informed or involved in decisions regarding her opioid pain management. Staff changed her medication from as-needed to routine dosing without documenting the reason or discussing risks, benefits, or alternatives with her. The resident later experienced withdrawal symptoms after a dose reduction and reported not being educated about opioid side effects or non-pharmacological pain interventions. Facility leadership confirmed the lack of resident involvement and documentation.
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