Failure to Timely Administer Physician-Ordered Medication Increase
Penalty
Summary
A resident with a history of myocardial infarction, congestive heart failure, generalized anxiety disorder, major depressive disorder, pain, post-traumatic stress disorder, alcohol use, and bipolar disorder was admitted to the facility and had a physician order to increase trazodone to 100mg at bedtime due to worsening and unstable major depressive disorder. The order was written on July 10, 2025, and entered to start on July 11, 2025. However, the resident did not receive the increased dose of trazodone as ordered and continued to receive the previous 75mg dose until July 13, 2025. The resident reported delays in starting new medication orders and specifically noted not receiving the increased trazodone dose when it was ordered to help with sleep. Review of the Medication Administration Record confirmed the delay in administering the increased trazodone dose. The Psychotropic Informed Consent form for the increased dose was signed by the resident on July 13, 2025, the same day the new dose was first administered. The Director of Nursing was unable to provide an explanation for the delay in administering the medication as ordered. Facility policy requires medications to be administered only upon the written order of an authorized prescriber.