Failure to Manage Medication Reordering and Physician Notification
Penalty
Summary
The facility failed to ensure proper consultation with a resident's physician when there was a significant need to alter treatment, specifically regarding the administration of the medication Nuplazid. The resident, who was cognitively intact and had a history of falls and behavioral issues, was prescribed Nuplazid to manage behaviors such as crawling on the floor and aggression towards staff. However, due to insurance constraints, the medication required reordering every 14 days, which the facility failed to manage effectively, resulting in 20 missed doses over two separate periods. The facility's policy required immediate notification of the nursing supervisor and the medical provider when medications were not available, but this protocol was not followed. The nursing staff did not inform the resident's physician about the missed doses or the need to reorder the medication, leading to a lapse in treatment. Interviews with staff revealed that there was a lack of a systematic approach to ensure timely reordering of the medication, and during a transition period between unit managers, the responsibility for reordering was not adequately managed. The resident's neurologist/psychiatrist and the facility's medical director both expressed that they should have been informed of the medication lapse. The consultant pharmacist noted that stopping Nuplazid abruptly could lead to the reemergence of behaviors and hallucinations. The facility's failure to adhere to its protocols for medication management and physician notification resulted in a significant deficiency in the resident's care.
Plan Of Correction
Plan of Correction: Approved March 27, 2025 1. Resident #1 was assessed for 5 consecutive days and reviewed with the Medical Director and determined to have no current negative outcomes. Care plan was reviewed and in concert with the resident’s needs. Medication error report was completed and shared with the IDT member, physician, pharm consultant and dispensing pharmacy. Consultant ordering Psychiatrist was updated on the omission and a follow up visit was provided/pending. 2. All residents experiencing changes in conditions or falls have the potential to be affected by this deficient practice. The DON conducted a review of all residents currently in the facility experiencing changes in condition, medications not being administered as ordered and falls to determine physician notifications were completed. No other deficiencies were found. 3. Measures that were put in place to ensure the deficient practice does not recur. The Unit Manager was educated on the policies titled Medication/Treatment Administration Documentation and Change in Resident's Condition, Medication/Treatment or status. The DON will conduct an audit of 10 residents a week with falls and/or a change in medical conditions to determine notification to the physician until 100% compliance for 4 consecutive weeks is sustained. Included in the audit will be a review to determine that the medical provider was notified of missed medication doses. The policies were reviewed and no changes were necessary. All staff responsible for Medication Administration Documentation were educated on the policy titled Medication/Treatment Administration Documentation. All staff responsible for Physician notifications and family notifications regarding changes of care and resident condition were educated on the policy titled Change in Resident's Condition, Medication/Treatment or status. The facility reviewed all orders with 14 day renewals on the MAR / TAR and changed the orders to standing orders so the order will not fall off. The Pharmacy will send reminders if additional authorization is needed prior to filling the medication. 4. Results of the above will be provided to the Quality Improvement Committee on an ongoing basis to monitor compliance. The Director of Nursing will be responsible for monitoring compliance and follow up as necessary. If 100% compliance is not found, the staff involved will be immediately counseled. The Quality Improvement Committee may make further recommendations including, but not limited to ongoing education, additional audits and/or process changes. 5. Corrective action will be completed by 05/18/2025. The Director of Nursing Services is responsible for implementation of this plan with the Facility Administrator having overall responsibility for the conduct of the plan.