Failure to Prevent Duplicative Psychotropic Medication Therapy
Penalty
Summary
A deficiency was identified when a resident with diagnoses including Chronic Obstructive Pulmonary Disease, heart failure, and depression was found to be receiving two medications, buspirone and escitalopram, both prescribed for depression. The resident's physician orders indicated that both medications had been administered concurrently since December of the previous year, with no documentation justifying the need for duplicative therapy. The resident's care plan included interventions to administer medications as ordered, but did not address the duplication. Review of the resident's Medication Administration Record confirmed that both medications were given as prescribed. Additionally, pharmacy consultant drug regimen reviews over several months did not include recommendations regarding the use of buspirone or escitalopram. During an interview, the DON stated she was unaware of the concurrent use of these medications for the same indication and acknowledged that this could be considered a duplication of therapy. Facility policy specified that psychotropic medications should not be given in excessive dosages.