Failure to Discontinue Unnecessary Medication for Resident
Penalty
Summary
A resident with multiple diagnoses, including chronic bronchitis, low back pain, and dementia, was admitted to the facility and prescribed guaifenesin ER 600 mg every 12 hours for congestion. Despite this ongoing prescription, multiple progress notes from a Nurse Practitioner over several months documented that the resident did not exhibit symptoms such as cough, congestion, shortness of breath, nasal discharge, or abnormal lung sounds. Medication administration records confirmed that the resident continued to receive guaifenesin ER as ordered from March through late June. Direct observations of the resident on several occasions revealed no signs of cough, congestion, or difficulty breathing. When questioned about the continued administration of guaifenesin despite the absence of symptoms, the Director of Nursing was unable to provide a clear rationale and suggested the medication order needed clarification. This sequence of events demonstrates that the facility failed to ensure the resident was free from unnecessary medications, as required.