Failure to Provide Prescribed Antipsychotic Medication and Follow Medication Error Protocols
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of schizophrenia was not provided with their prescribed Seroquel (an antipsychotic medication) for several days. The physician's orders specified that the resident was to receive Seroquel 25 mg at three different times daily. However, nursing progress notes repeatedly documented that the medication was not available in the medication cart and was on order or awaiting delivery over a period spanning multiple days. There was no documentation indicating that the medication was administered during this time. Interviews with nursing staff, including LPNs, RNs, the ADON, and the DON, revealed that facility policy requires staff to check the contingency medication supply, contact the pharmacy for stat delivery, and notify the physician when a medication is unavailable. Staff also indicated that daily assessments should be completed and documented, and that missed medications constitute a medication error requiring risk management review. Despite these protocols, there was no evidence in the medical record that the pharmacy or physician was notified, or that assessments were completed for the missed doses of Seroquel. Additionally, the surveyor confirmed that the facility's contingency supply did contain Seroquel 25 mg, which could have been used to administer the medication. The lack of documentation and failure to follow established procedures resulted in the resident missing multiple doses of a critical medication, with no evidence of appropriate follow-up or communication as required by facility policy.