Nurse Increased Medication Dose Without Physician Order
Penalty
Summary
A licensed nurse, specifically the Assistant Director of Nursing (ADON), increased the dose of Seroquel (Quetiapine) for a resident without obtaining a physician's order. The resident's medication was changed to 50 mg twice daily, as reflected in the Medication Administration Record (MAR) from December 2024 through April 2025. Review of the resident's electronic health record and order summary did not show any physician authorization for this dosage increase. During interviews and record reviews, the ADON acknowledged entering a verbal order for the increased dose but could not provide evidence of a physician's directive for this change. The Director of Nursing (DON) confirmed that the ADON acted beyond the scope of her license by increasing the medication dose without a physician's order. This action was not supported by any documented indication or authorization from a physician.