Failure to Provide Prescribed Antipsychotic Medication Due to Pharmacy and Communication Lapses
Penalty
Summary
A resident with diagnoses including bipolar disorder, psychotic disorder with delusions, anxiety disorder, and major depressive disorder was admitted to the facility and had a physician's order for quetiapine fumarate, an antipsychotic medication, to be administered at bedtime for psychosis. The resident's care plan specified that psychotropic medications were to be administered as ordered and monitored for effectiveness. However, the medication was not received from the pharmacy and was unavailable for administration for a period of 32 days, from the date the order was written until it was eventually filled by the pharmacy. The facility's process involved faxing the medication order to a community pharmacy, but there was no documented policy or procedure for ordering new medications. The delay in receiving the medication was not identified by staff until a nurse, while reviewing medications with the resident's family, discovered the omission. There was no communication among staff regarding the medication's unavailability, and the issue was only addressed after the family inquired with the pharmacy and the order was resent. As a result, the resident did not receive the prescribed antipsychotic medication for over a month.