Failure to Provide Ordered Antipsychotic Medications for Resident with Serious Mental Illness
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder, bipolar type, was not provided with their ordered antipsychotic medications, specifically risperidone and Seroquel, for multiple consecutive days following admission. The resident did not receive 12 consecutive doses of risperidone and five consecutive doses of Seroquel due to the medications not being available in the facility. Documentation in the medication administration record repeatedly noted that the medications were "waiting on pharmacy" or "on order," and there was no evidence that the physician was notified about the unavailability of these vital medications. Staff interviews revealed that certified medication aides (CMAs) and nurses were either unaware of the medication orders or did not document notifications to the charge nurse or pharmacy regarding the missing medications. The DON and administrator were not made aware that the medications were unavailable, and the physician confirmed they had not been notified nor had they ordered the medications to be placed on hold. The facility's existing policy required physician notification if three consecutive doses of a vital medication were withheld, refused, or not available, but this protocol was not followed in this case. During the period when the resident was not receiving their prescribed antipsychotic medications, they exhibited escalating behavioral symptoms, including delusions, hallucinations, agitation, and threats toward staff, which ultimately led to emergency room visits and in-patient psychiatric treatment. The failure to ensure the availability and administration of ordered medications for a resident with a serious mental illness constituted a deficiency in providing necessary behavioral health care and services as required.