Failure to Discontinue Duplicate Cardiac Medication Orders
Penalty
Summary
A deficiency occurred when the facility failed to identify and address a medication order discrepancy for a resident with multiple cardiac diagnoses, including hypertension, atherosclerotic heart disease, atrial fibrillation, and a coronary angioplasty implant. Upon admission, the resident was prescribed Diltiazem 60 mg to be taken four times daily. Later, a physician's note indicated a switch to Cardizem CD 240 mg once daily, and a new order for Cardizem LA 240 mg once daily was entered. However, the original Diltiazem 60 mg order was not discontinued, resulting in both medications being administered concurrently. The Medication Administration Record (MAR) showed that both Cardizem LA 240 mg and Diltiazem 60 mg were scheduled and administered at overlapping times. The monthly medication regimen review (MRR) conducted in February did not address the duplicate therapy, and the March MRR only raised the issue in a written recommendation to verify the necessity of both medications. This recommendation was not signed or addressed by the attending physician, and the duplicate orders remained active. Interviews with the Director of Nursing confirmed that the pharmacy's recommendations had not been acted upon and that the duplicate medication orders constituted a medication error. Facility policy required timely review and resolution of such irregularities, including immediate physician notification if resident safety was at risk, but these steps were not followed. The failure to discontinue the previous order and to act on the pharmacist's recommendations led to the ongoing administration of duplicative therapy.
Plan Of Correction
Element 1: Resident #18 order for Diltiazem 60mg was discontinued. Physician was notified of medication error during survey. Element 2: An audit of Pharmacy Medication Reviews was completed for the last 30 days to ensure reviews were completed by Physician and had documented response from the Physician in Residents' medical record. Any concerns were corrected. Element 3: Physicians were reeducated on reviewing and completing documentation of Pharmacy Medication Reviews in the Residents' medical record. Element 4: Unit Manager/Designee will complete random monthly audits of Pharmacy Medication Reviews to ensure all reviews have been documented with findings submitted to DON who will report findings to QAPI for review and recommendations. Element 5: Director of Nursing is responsible for maintaining compliance.