Failure to Obtain Consent and Prevention of Duplicate Medication Administration
Penalty
Summary
The facility failed to obtain a signed consent for treatment with an antipsychotic medication for a resident diagnosed with dementia, depression, anxiety, and other chronic conditions. The resident was prescribed Fluoxetine for depression, but a review of the medical record did not identify a consent form for this treatment. Additionally, the resident's care plan did not mention the use of medication for depression, despite the ongoing prescription and administration of Fluoxetine. The Director of Nursing confirmed that a consent form could not be found for this medication. Another deficiency was identified when a resident with a history of hypertension, heart disease, and atrial fibrillation was administered duplicate medications containing diltiazem. The resident's physician ordered a switch from Diltiazem 60 mg four times daily to Cardizem LA 240 mg once daily, but the original order for Diltiazem 60 mg was not discontinued. As a result, the resident received both medications concurrently, as documented in the Medication Administration Record. The Director of Nursing acknowledged this as a medication error, and facility policy requires monitoring to prevent such errors.
Plan Of Correction
Element 1 Resident #52 was not on an Antipsychotic medication at the time of the survey. Consent was obtained for Antidepressant Fluoxetine. Resident #18 order for Diltiazem 60mg was discontinued, Physician was notified of medication error during survey. Element 2 An audit of Antidepressant medication orders was completed to ensure consents were present for all Antidepressant medications. Any concerns were corrected. An audit of Pharmacy Medication Reviews were 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 Director of Nurses/Designee completed re-education to Licensed nurses on documentation of obtaining consents for Antidepressant medications and discontinuing orders per Physician order. Any licensed nurse not educated by May 20, 2025 will be educated on their next scheduled shift. Licensed Nurse will verify that there is a consent signed for any new Antidepressant Medications as part of the report during shift change. Nurse managers will review during morning meeting to ensure medication orders were discontinued per Physician changes of medications and all consent have been obtained for Antidepressant medications. Element 4 Unit Manager/Designee will complete random weekly audits X4 weeks of medication changes to ensure orders were discontinued and any resident with new Antidepressant medications has a signed consent. Results of findings submitted to DON who will report findings to QAPI for review and recommendations. Element 5 Director of Nursing is responsible for maintaining compliance.