Failure to Document Indications for Medication Orders
Penalty
Summary
The facility failed to ensure that all medication orders for two residents included a proper indication or diagnosis for use, as required. For one resident with severe cognitive impairment and multiple diagnoses including cerebrovascular disease, dementia, hypertension, depression, hyperlipidemia, and a history of transient ischemic attack, provider orders for several medications such as aspirin, atorvastatin, clopidogrel, losartan, and pantoprazole did not have an associated indication or diagnosis. This was confirmed during a review of the resident's chart by a registered nurse, who acknowledged the absence of proper indications for these medications. For another resident with diagnoses of bipolar disorder, PTSD, and chronic pancreatitis, a provider order for valacyclovir also lacked a documented diagnosis or indication for use. The DON confirmed the expectation that all medication orders should have a diagnosis or indication attached. The facility's medication administration policy requires staff to be able to state the indication for all medications, but this was not followed in these cases.