Failure to Ensure Timely Administration of Antidepressant Medication
Penalty
Summary
Resident 89, who was admitted with diagnoses including depression and a history of cerebrovascular accident, was prescribed Paxil 40 mg daily for depression. According to the resident's medication administration records (MAR) and pharmacy delivery records, the facility failed to ensure the resident received Paxil from 5/31/2025 until 6/04/2025. The pharmacy delivery records confirmed that there was no Paxil delivered to the facility to cover these dates, resulting in missed doses for the resident. Interviews with the resident, nursing staff, and the Director of Nursing (DON) revealed that the medication was not available during this period, and the staff had to request a new supply from the pharmacy. The resident reported a time when the facility ran out of Paxil, and the DON confirmed the medication was not delivered in time for scheduled administration. The MAR indicated that the medication was not administered during the gap, and the pharmacy confirmed the absence of delivery for the missing days. Facility policies required timely reordering of medications and immediate action when medications were unavailable, including notifying the physician and monitoring the resident. However, these procedures were not followed, as there was no evidence of timely reordering or alternative arrangements during the period when Paxil was unavailable. This resulted in the resident missing several doses of a significant medication prescribed for depression.