Failure to Administer Antipsychotic Medication as Prescribed
Penalty
Summary
The facility failed to ensure that pharmaceutical services met the needs of a resident, specifically in the acquisition and administration of the antipsychotic medication Nuplazid. The resident, who was cognitively intact and had a history of falls, paranoid thoughts, and hallucinations, was prescribed Nuplazid to manage these symptoms. However, the medication was not administered for 20 doses due to lapses in reordering, which was required every 14 days per insurance policy. The facility's policy required that medication discrepancies be reported and addressed, but no medication error reports were completed for the missed doses. The deficiency occurred because the Licensed Practical Nurse (LPN) Unit Manager was unaware of the need to physically write a new order every 14 days for the medication, mistakenly believing it could be reordered like other medications. This misunderstanding led to periods where the medication was not administered, contributing to the resident's behavioral issues, such as refusing care and placing themselves on the floor. The facility's interim Director of Nursing acknowledged that the medication required a new prescription every 14 days and that the cart nurses were responsible for alerting unit managers when the medication was running low. Interviews with the Neurologist/Psychiatrist and the Consultant Pharmacist highlighted the importance of Nuplazid for the resident's mental health and the risks associated with abruptly stopping the medication. The facility's failure to reorder and administer the medication as prescribed resulted in the resident not receiving the necessary treatment to manage their condition. The Medical Director emphasized the facility's responsibility to ensure residents receive their medications as ordered and to notify the physician if there are any lapses in administration.
Plan Of Correction
Plan of Correction: Approved March 27, 2025 1. Resident #1 had an immediate review of his Medication Administration Record [REDACTED]. Resident was assessed and monitored for 5 consecutive days to monitor for adverse effects. None were noted. MD was notified regarding medication omission. Medication error report was completed and shared with the IDT member, pharm consultant and dispensing pharmacy. Resident’s care plan was reviewed and in concert with residents current needs. A reminder was added to the DON, ADON and Unit Managers calendars every 14 days for Res #1's Nuplazid renewal. An additional order was entered to reorder the medication every 14 days to trigger the medication nurse to ensure medication is reordered timely. 2. All residents on 14 day renewal medications, with medications that have special medication ordering needs or medications requiring a new script have the potential to be affected by this deficient practice. The facility reviewed all other residents to ensure there were no other special medication ordering needs. None were identified. The DON conducted a full house audit of all residents on medications requiring a new script or preauthorization and no other issues were found. The facility changed all orders with 14 day renewals on the MAR / TAR to be entered as standing orders so that a new script is not required each time so this problem does not recur. The pharmacy will notify the facility if a preauthorization is needed. 3. The Unit Manager was educated on the Ordering Medications/Treatments from Pharmacy policy and the Medication/Treatment Discrepancy/Error policy. The policies titled Ordering Medications/Treatments from Pharmacy and Medication/Treatment Discrepancy/Error were reviewed and no changes were necessary. 4. Measures that were put in place to assure the deficient practice does not recur: - All staff responsible for Medication / Treatment Administration were educated on the policies titled Ordering Medications/Treatments from Pharmacy and Medication/Treatment Discrepancy/Error. - The DON will conduct weekly audits of the resident population with 14 day renewals to ensure orders are present. All current and new 14 day renewal orders will be audited weekly until 100% compliance is sustained x 4 weeks. If 100% compliance is not found, the staff involved will be counseled immediately. 5. Results of the above will be provided to the Quality Improvement Committee on an ongoing basis to monitor compliance. The Quality Improvement Committee may make further recommendations including, but not limited to ongoing education, additional audits and/or process changes. 6. The Director of Nursing will be responsible for monitoring compliance of the corrective plan with the facility administrator having overall responsibility for the conduct of the plan. Corrective action will be completed by 05/18/2025.