Failure to Prevent Unnecessary Drug Use and Excessive Medication Regimens
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs, specifically regarding the use of antibiotics and the administration of medications for pain and anxiety. For one resident with a history of ESBL, neurogenic bladder, sepsis, and recurrent UTIs, records showed prolonged and overlapping use of multiple antibiotics, including Macrobid, Zyvox, Meropenem, Levaquin, and Imipenem-Cilastatin. Despite the discontinuation of a Foley catheter and multiple courses of IV antibiotics, the resident continued to receive oral Macrobid concurrently. The Director of Nursing acknowledged that the resident had received numerous rounds of antibiotics and questioned the ongoing effectiveness of the oral antibiotic, especially as the resident was also on hospice care. Another resident, who was severely cognitively impaired, dependent for mobility, and receiving hospice care for multiple diagnoses including acute respiratory failure and heart failure, was administered both opioid and anti-anxiety medications. Medication administration records indicated that Lorazepam and Morphine Sulfate were frequently given simultaneously or within minutes of each other on numerous occasions over several months. Staff relied on nonverbal pain assessment tools due to the resident's inability to communicate pain levels, and the DON confirmed that the two medications should not have been administered together. These findings demonstrate that the facility did not adequately monitor or review the necessity, duration, and dosing of medications for these residents, resulting in the use of unnecessary drugs and potentially excessive medication regimens. The deficiencies were identified through record review and staff interviews, highlighting lapses in medication management and oversight for residents with complex medical needs.