Failure to Discontinue Unnecessary Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically for a resident diagnosed with anxiety, hypertension, and acute respiratory failure. The resident was receiving Loratadine 10 mg daily for seasonal allergic rhinitis, as noted in the monthly pharmacy review dated October 29, 2024. The pharmacist recommended that the administration of Loratadine should be limited to the allergy season to avoid adverse events from long-term use and suggested a reevaluation of its necessity, possibly considering a trial discontinuation or PRN (as needed) period. Despite the physician agreeing to the pharmacist's recommendation on October 31, 2024, the resident's clinical record showed that the standing order for Loratadine, which began on February 13, 2024, continued without a stop date. This oversight was confirmed during an interview with the Director of Nursing on January 8, 2024, indicating that the medication should have been discontinued as per the pharmacy's recommendation and the physician's response.
Plan Of Correction
On January 9, 2025, Loratadine was discontinued from the profile of Resident R30 as recommended by the Consultant Pharmacist. Going forward, all Pharmacy Consultant reports will now require a review by our Resident Care Coordinators after being scanned into the EMR system to ensure that all recommendations were addressed by the physician and that all orders were followed accordingly. The Director of QI will review the Pharmacy Consultant reports monthly for 6 months to ensure accuracy and then quarterly for 3 months. The Pharmacy Consultant will also inform the Director of Nursing each month that all recommendations from the previous month were addressed appropriately.