The resident at Towson Rehabilitation and Healthcare Center had been admitted in September with dementia, anxiety disorder, depression, and altered mental status. By early October, staff documented the person was showing "increased anxiety and restlessness" and making "repeated attempts to ambulate without assistance."
A psychiatrist initially prescribed Buspar 5 mg twice daily for anxiety management on October 2. The resident's caregiver was notified and authorized that medication, according to inspection records.
But one week later, the situation had deteriorated.
The psychiatrist returned on October 9 after complaints of "ongoing yelling and agitation." The nurse manager and floor nurse told the doctor the resident showed "moderate aggression and anxiety." During the evaluation, the resident appeared "restless, verbally aggressive, and irritable" with an "intense" affect showing "ongoing agitation and behavioral dysregulation."
The psychiatrist increased the Buspar to 7.5 mg twice daily. The doctor also started Hydroxyzine 10 mg twice daily as needed for 14 days. Hydroxyzine is an antihistamine prescribed for short-term anxiety relief.
Federal inspectors found no documentation that the resident's responsible party was notified of either medication change.
When confronted about the missing family notification on October 23, the Director of Nursing told inspectors that the Assistant Director of Nursing had spoken to someone verbally but "could not say who the ADON spoke to."
An hour later, nursing leadership scrambled to produce evidence. The Director of Nursing and Administrator handed inspectors a signed timeline claiming the family member had been notified on October 10 about the medication changes. The Assistant Director of Nursing had signed the form.
But inspectors discovered the timeline wasn't created until October 22 — the day they began investigating the complaint. No documentation existed in the resident's medical record showing the caregiver had been notified or had approved the medication increase and addition.
The violation represents a breakdown in basic communication requirements. Federal regulations mandate that nursing homes immediately notify residents, their doctors, and family members of significant changes affecting care, including medication adjustments for behavioral symptoms.
For families of dementia patients, medication notifications carry particular weight. Anti-anxiety drugs and antihistamines can cause sedation, confusion, and increased fall risk in elderly residents with cognitive impairment. Family members rely on these notifications to understand changes in their loved one's condition and advocate for appropriate care.
The resident's case illustrates how quickly behavioral symptoms can escalate in dementia care. Within one week, staff observations progressed from noting restlessness to documenting "verbal aggression" and "behavioral dysregulation." The psychiatrist's assessment suggested a possible "exacerbation of underlying psychiatric condition."
Yet despite the significant clinical changes and dual medication adjustments, the facility failed to follow through on the fundamental requirement to keep the family informed.
The inspection occurred during a complaint survey, suggesting someone had raised concerns about care at the facility. Inspectors reviewed four residents' records and found the notification failure affected one person.
When nursing leadership realized they had no documentation of family contact, they attempted to create a paper trail retroactively. The hastily produced timeline, signed only after inspectors arrived, highlighted the facility's awareness that proper notification procedures had been ignored.
The violation received a "minimal harm" rating, indicating inspectors believed the failure created potential for actual harm rather than causing immediate injury. However, the finding underscores how administrative breakdowns can leave families uninformed about critical changes in their relatives' care.
For the resident involved, the combination of increased Buspar and new Hydroxyzine represented a significant shift in psychiatric treatment. The medications target different pathways — Buspar affects serotonin receptors while Hydroxyzine blocks histamine — creating potential for interaction effects and cumulative sedation.
The facility's inability to identify who received the alleged verbal notification raises questions about the reliability of their communication systems. In an environment where multiple staff members interact with families, proper documentation becomes essential for ensuring continuity of care and family engagement.
The case reflects broader challenges in dementia care, where behavioral symptoms often require rapid medication adjustments. But federal requirements for family notification exist precisely because these vulnerable residents depend on advocates to monitor their treatment and wellbeing.
The resident's family remained unaware of the medication changes for at least two weeks, missing the opportunity to observe effects and provide input during a critical period of psychiatric intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Towson Rehabilitation and Healthcare Center from 2025-10-23 including all violations, facility responses, and corrective action plans.
Additional Resources
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