Failure to Implement Physician-Ordered Medication Changes
Penalty
Summary
The facility failed to follow physician's orders regarding a Gradual Dose Reduction (GDR) of psychotropic medication for a resident with diagnoses including dementia, psychotic disorder, and depression. The psychiatric nurse practitioner ordered a decrease in Risperdal and an increase in sertraline, but these changes were not implemented in the resident's medication administration. The resident continued to receive the previous doses, and there was no documentation that the new orders were processed. Nursing progress notes indicated the resident experienced no psychosocial distress initially, but later exhibited hallucinations and increased confusion. The medication orders were eventually updated after a delay, following a pharmacy consultation that identified the discrepancy. Interviews with facility staff revealed that the failure to update the medication orders was due to a lack of policy regarding the implementation of physician orders, relying instead on standard nursing practice. The assistant director of nursing and the regional director of clinical services confirmed that the medication changes were not made as ordered, and that staff were unaware the GDR had not actually been implemented when they observed changes in the resident's behavior.