Failure to Monitor for Adverse Effects of High-Risk Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not providing appropriate monitoring for adverse effects associated with certain high-risk medications. For two residents receiving antibiotics, there was no documented monitoring for adverse effects. One resident was prescribed azithromycin for pneumonia prophylaxis without an order or documentation for monitoring potential side effects, despite the medication's known risks, especially in elderly patients. Interviews with nursing and pharmacy staff confirmed the absence of such monitoring and emphasized its importance for timely intervention and prevention of complications, including antibiotic resistance. Another resident was prescribed amoxicillin as a PRN order for dental procedure prophylaxis, but the order lacked instructions for monitoring adverse effects. The medication was only administered once, but staff and a nurse practitioner noted that the PRN order increased the risk of medication errors and that monitoring for adverse effects was not in place. Facility leadership acknowledged that the order should have been written as a one-time dose and that monitoring for adverse effects was necessary to ensure safe use of the antibiotic. A third resident was prescribed both aspirin and clopidogrel for stroke prophylaxis, but there was no order or documentation for monitoring adverse effects such as bleeding. Nursing staff and facility leadership confirmed the lack of monitoring and highlighted the importance of such oversight to prevent and address potential adverse reactions. Product information for these medications, provided by the facility, listed significant risks such as hemorrhage and other side effects, underscoring the need for monitoring that was not implemented.