Based on clinical record review and interviews with staff, it was determined that the facility failed to inform a resident's family member when a medication was prescribed for one of five residents reviewed (Resident R4).Findings include:
Clinical record review for Resident R4 revealed an Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated July 10, 2019, which indicated that the resident was admitted to the facility July 3, 2019, and was severly cognitively impaired. Diagnoses included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), unspecified pain, rotator cuff tear and lower back pain related to a pinched nerve.
Review of physician's notes for Resident R4 revealed a note, dated July 11, 2019, which indicated that the resident's daughter was concerned that Tramadol (a pain relieving medication) was making the resident's dementia worse and requested that the medication be held.
Review of the July 2019 Medication Administration Records (MARs) revealed that the medication was stopped on July 11, 2019.
Continued review of physician's notes for Resident R4 revealed an evaluation note, completed on July 18, 2019, for an evaluation of pain. The note indicated that the resident came to the facility due to being unable to care for himself due to severe pain, that the resident had Alzheimers, did not know what medications he was taking, and had nonsensical speech. The resident was observed by the physician to have pain to touch and appears uncomfortable. The physician noted that the resident's family member requested to discontinue Tramadol due to concerns of increasing confusion. The physician also noted to restart the Tramadol due to the resident being in pain.
Review of the July 2019 MARs revealed that the medication was restarted on July 18, 2019.
Review of nurses notes revealed a note, dated July 18, 2019, at 11:11 p.m. which indicated that the physician restarted Tramadol that evening and that Resident R4 reported relief from back pain.
Continued record review revealed that there was no documentation available in the record to indicate that the resident's family member had been notified of the physician's order to restart the Tramadol.
Further record review revealed a nurses note, dated July 24, 2019, at 1:00 p.m. which indicated that Resident R4's family member observed the nurse administering the Tramadol to the resident. The nurse noted that the resident was restarted on Tramadol due to complaints of back pain. The family member requested that the medication be discontinued again at that time.
Review of the July 2019 MARs revealed that the medication was discontinued again on July 24, 2019.
Interview on August 16, 2019, at 12:15 p.m., the Director of Nursing and the Assistant Director of Nursing confirmed that Resident R4's family member should have been notified when the resident was restarted on Tramadol.
The facility failed to inform a resident's family member when a medication was prescribed.
28 Pa Code 201.29(j) Resident rights
Previously cited 7/31/18