Failure to Prevent Duplicate Antipsychotic Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation and administration of antipsychotic medications for two residents with severe cognitive impairment and multiple psychiatric diagnoses. For one resident with psychosis, depression, anxiety, and atrial fibrillation, medical records showed duplicate orders for Risperidone and Risperdal, resulting in the resident receiving both medications at the same dosage and time over several months. This duplication was reflected in the Medication Administration Records (MAR) from January through mid-April, with both the brand and generic forms administered concurrently each evening. Similarly, another resident with dementia, PTSD, anxiety, depression, and psychotic disorder had duplicate orders for Quetiapine and Seroquel, leading to both being administered at the same dosage and time over multiple months. The MARs indicated this duplication persisted from late February through mid-April, despite a pharmacist's report identifying the duplicate orders and requesting discontinuation of one. The Director of Nursing confirmed the presence of these duplicate orders and that the nurse practitioner had been notified.