Failure to Notify Physician and Administer Antipsychotic Medication
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify and consult with a physician after a resident missed multiple doses of a prescribed antipsychotic medication, Seroquel, over several days. The resident, who had a diagnosis of schizophrenia, had physician orders for Seroquel to be administered three times daily. Nursing progress notes repeatedly documented that the medication was not available in the medication cart and was either on order or awaiting delivery for an extended period, spanning from 12/21/24 through 12/30/24. Despite these ongoing missed doses, there was no documentation that the resident's physician was notified of the missed medication, as required by facility policy. Interviews with nursing staff, including LPNs, RNs, the ADON, and the DON, revealed that facility policy and staff expectations were to check the contingency medication supply, contact the pharmacy for stat delivery, and notify the physician when a medication was unavailable. Staff also indicated that these actions, as well as any assessments related to missed medications, should be documented in the resident's medical record. However, the surveyor found no evidence in the record that the physician was notified, the pharmacy was contacted for stat delivery, or that any assessments were completed regarding the missed Seroquel doses for the resident during the period in question. Additionally, the facility's contingency medication supply was found to contain Seroquel 25 mg, which could have been used to prevent missed doses. Despite this, the medication was not administered, and the required notifications and documentation were not completed. The facility's own policies on notification of changes and medication error reporting were not followed, resulting in a failure to ensure timely physician consultation and appropriate documentation when the resident did not receive their prescribed medication.