LITTLETON,CO-LIFE CARE CENTER OF LITTLETON

Based on record review and interviews, the facility failed to ensure residents were fully informed of their total health status, informed of proposed care and/or treatments for one (#344) of five residents reviewed for medications out of 38 sample residents.

Specifically, the facility failed to accurately and fully inform and educate Resident #344 of the five medications with a black box warning he was being administered as part of his medication regimen.

Resident #344 and the residents representative were interviewed on 3/24/22 at 9:16 a.m. They said they did not receive education about the risks and benefits of the five black box warning medications Resident #344 was being given.

Regarding Resident #344 ‘ s [MEDICATION(S)] medication, they said they did not know about the
constipating side effects, which Resident #344 said constipation really affected him last week.

Regarding Resident #344 ‘ s tegretolmat (anticonvulsant) medication, they said they did not know why Resident #344 was taking it.

Regarding Resident #344 [MEDICATION(S)] medication Resident #344 and the representative guessed he was taking it because of retaining fluid and it made you go pee. However they said they had not been educated on other side effects or benefits. Resident #344 and his representative said the staff had a hurriedness and had rushed around. They said the doctors and nurses did not tell them about the black box warning medications and side effects and there was no consent by Resident #344 to use the medication based on education for the medications.

Regarding Resident #344 ‘ s [MEDICATION(S)] medication, they thought it was for blood clots in the lungs, but did not know the side effects of the medication, possibly bruising or bleeding, or how long he needed to take it. The resident representative said she asked one time, how long he needed the medication and they (nursing staff) said maybe all his life. The representative then asked the staff when do they (nursing staff) check if the blood clots are gone? She said she was told the staff do not check. The representative then said she asked, how do they know he still needs it? Resident #344 and his representative had many unanswered questions regarding the medication.

The home medication list assessment form the nurse filled out and completed at admission (for medication reconciliation and education) for Resident #344 was requested from the NHA on 3/24/22 at 12:44 p.m. The NHA responded that they did not have the home list of medications but had what he was admitted with from the hospital.

LPN #9 was interviewed on 3/24/22 at 12:09 p.m. She said the expectation for education for medication with black box warning for the residents was when they are admitted they are educated and may have already been at the hospital. LPN #9 said we call the doctor to reconcile the medications and then we go to the residents room as part of the admission process. LPN #9 said, we ask the resident why they are taking a medication and if they are aware we can ask if they feel comfortable with the medication. LPN #9 said we get the black box warning information from the pharmacy with the side effect summary. LPN #9 also said when you look at the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #9 said they have no resident consent sheet for black box warning medications. LPN #9 said the medication education would be documented in the admission packet listed on the home medication list.

The DON said the expectation for resident education for medications with black box warnings was dependent on what the medication was. The DON said if medication was [MEDICATION(S)], for example, the resident would need education on the side effects. The DON said they would provide education upon admission during the nursing: home medication list reconciliation.

The facility pharmacist was interviewed on 3/24/22 at 12:53 p.m. He said there is a black box warning on certain medications because the food and drug administration (FDA) requires it to draw attention to potential side effects. He said education about the medication should occur when prescribed.