Failure to Administer Psychotropic Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of anxiety disorder, dysthymic disorder, major depressive mood disorder (MDD), and post-traumatic stress disorder (PTSD) did not receive their prescribed Rexulti medication for several days. The resident was admitted with these mental health diagnoses and had a care plan in place that included administering psychotropic medications as ordered and monitoring for adverse reactions. Despite a physician's order to administer Rexulti 1mg at bedtime for depression, the medication was not given on multiple consecutive days due to it not being available at the facility. The medication administration record (MAR) and interviews confirmed that the resident did not receive Rexulti as prescribed from 3/19 through 3/24, and the facility did not complete a timely refill request to the pharmacy during this period. The consulting pharmacist confirmed that the facility failed to request a refill for Rexulti in a timely manner, resulting in a gap in medication administration. The pharmacy policy required refill requests to be made 2-3 days before the medication ran out, but the facility did not follow this process, leading to missed doses. The resident experienced an exacerbation of anxiety due to the missed medication, as documented in a psychiatric evaluation. Facility policies required medications to be administered as ordered and in accordance with professional standards, but these were not followed, resulting in the deficiency.