Medication Orders Lacking Required Indications
Penalty
Summary
The facility failed to ensure that medication orders for several residents included the required indications for use, as identified through interviews and document review. For three out of five residents reviewed, provider orders for multiple medications did not specify the medical reason or diagnosis for which the medication was prescribed. For example, one resident with a complex medical history including dementia, agitation, delusional disorders, hypothyroidism, and other conditions, had orders for medications such as Miralax, furosemide, hydrocortisone cream, magnesium oxide, docusate, Senna S, and lisinopril without documented indications. Additionally, the resident's care plan did not address certain diagnoses or problems related to some of these medications. Another resident with severe cognitive impairment and multiple diagnoses, including stroke, diabetes, hypertension, and dementia with psychotic disturbance, had orders for melatonin and ondansetron without documented indications. The facility's policy required that all medication orders include the name, dosage, route, frequency, and diagnosis for usage, and that nurses verify the completeness and accuracy of transcribed orders. However, the lack of documented indications for these medications constituted a failure to comply with both facility policy and regulatory requirements.