Failure to Prevent Significant Medication Error During Abrupt Medication Discontinuation
Penalty
Summary
Facility staff failed to recognize and appropriately manage the abrupt discontinuation of multiple medications, including Escitalopram and Lorazepam, for a resident with a history of major depressive disorder and anxiety. The resident's medication orders were changed following a visit to a renal clinic, which included stopping several medications without tapering, contrary to facility policy and clinical guidelines. The LPN who received the new orders did not question the abrupt discontinuation or notify the resident's primary physician prior to implementing the changes. The primary physician later stated he was not aware of the medication changes and would not have agreed to stopping the medications without a taper. Following the discontinuation, the resident exhibited increased tearfulness and distress, as observed by staff and documented in nursing progress notes. Staff noted that the resident had not been herself since the medication changes, and attempts to clarify the orders with the renal clinic were initially unsuccessful. The deficiency was identified through observation, interview, and record review, revealing that staff did not follow established protocols to prevent significant medication errors and failed to minimize adverse consequences by not adhering to clinical guidelines for medication management.