Failure to Prevent Duplicate PPI Therapy in a Resident with GERD
Penalty
Summary
A deficiency occurred when a resident with a history of GERD, diabetes, kidney disease, and heart issues was prescribed and administered two proton pump inhibitors (PPIs), pantoprazole (Protonix) and omeprazole (Prilosec), at the same time. The resident's medical record showed that Prilosec had been prescribed for GERD and continued after a recent hospitalization, while Protonix was added upon the resident's return from the hospital. Nursing staff did not identify or address the duplicate therapy, and the duplicate medications were not flagged in the electronic medical record system. The Licensed Vocational Nurse acknowledged that Prilosec should have been discontinued and that the physician should have been notified about the duplicate PPI therapy. The facility's consultant pharmacist confirmed that there was no clinical justification for the resident to be on both PPIs simultaneously and that this practice would not provide additional benefit. The facility's policies required ongoing review of medication regimens for indications, doses, duration, and potential adverse consequences, but these procedures were not followed in this case. The medical director was not reached for comment during the survey.