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Based on record review and interview, the facility failed to include the patient/family, in the implementation and ongoing plan of care, related to medication teaching, symptom management and discharge planning. (Patient ID# 1)

Findings include:

Record review of HHS Triage intake for Patient ID #1 revealed Patient ID #1 family member placed a telephone call to HHS Intake on 9/16/2021 at 4:21 pm. The family member of Patient ID # 1 stated "the family started to notice that the patient would not eat or drink. The patient started to be less and less responsive. The patient had been seen by Physician Staff ID # 57, but the family was unaware that he had ordered diazepam." The complainant "strongly believed the resident suffered an adverse effect from the medications provided by (Physician ID #57)."

Medical record review of Patient ID #1 on 2/15/2023 at 1:30 pm with Case Manager Staff ID # 60, revealed that patient was admitted from home for rehabilitation on 8/12/2021 at 7:23 p.m. He had been referred by his house call provider team. Diazepam was not listed on the handwritten medication list or computerized admission home medication reconciliation. "Diazepam 5 mg by mouth TID" was ordered by Physician Staff ID # 57 on admission for "left-sided tone". There was no evidence of patient/family communication or education regarding the addition of this benzodiazepine to the patient's medication regimen and possible side effects by the physician, pharmacy or nursing. Physician ID # 57 daily progress notes on 8/26/21 at 11:07 am reflect that the "patient is evaluated today and over the past few days, he has acted much more lethargic, which seems to be waxing and waning .... We have discontinued all his benzodiazepines, which were used to decrease his left-sided tone. Few days ago we also discontinued his Klonipin, which someone had initiated for his anxiety and now he will be on no benzodiazepines at all and hopefully, we can see whether or not he wakes up." There was no nursing, pharmacy or physician documentation reflecting medication education with patient or family.

Record review of facility's "Patients Rights and Responsibilities" form on 2/15/2023 at 3:50 pm, the document stated "You or your legal representative have the right to: 5. Receive information about your health status, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care."

Interview with Case Manager, Staff ID #60 on 2/15/2023 at 1:45 pm, she confirmed there was no nursing, pharmacy or physician documentation reflecting medication education with Patient ID #1 patient or family.

Interview with Case Management Director Staff ID # 63 on 2/15/2023 at 3:20 pm, she confirmed that the pharmacist is not a part of the weekly "Interdisciplinary Team" rounds or discharge planning process.