Failure to Document Indications for Use on Medication Orders
Penalty
Summary
The facility failed to ensure that medication orders for a resident included clear indications for use, as required to prevent unnecessary drug administration. Review of one resident's medication orders revealed that multiple prescribed drugs, including aspirin, atorvastatin, finasteride, levothyroxine, pantoprazole, psyllium, solifenacin, tamsulosin, thiamine, and vibegron, did not have documented indications for use in the medical record. This omission was confirmed during interviews with a trained medication aide, a registered nurse, and a licensed practical nurse, all of whom acknowledged that medication orders should specify the reason or diagnosis for each drug prescribed. The resident in question had a complex medical history, including moderately impaired cognition, dementia, muscle weakness, Wernicke's encephalopathy, hypertension, hypothyroidism, urinary incontinence, type 2 diabetes, and alcohol use in remission. Despite these diagnoses, the medication administration records lacked specific indications linking each medication to the resident's conditions. The director of nursing and nursing staff verified during interviews that the facility's expectation is for all medication orders to include an appropriate indication, which was not met in this case.