Failure to Administer Psychotropic Medication as Ordered
Penalty
Summary
A resident with a primary diagnosis of Paranoid Schizophrenia, along with other medical conditions including thyrotoxicosis, noncompliance with medication regimen, cannabis abuse with psychotic disorder with hallucinations, major depressive disorder, anxiety, and insomnia, was not administered her prescribed psychotropic medication, Ativan 0.5 mg, as ordered by her physician. The resident missed a total of ten doses over the course of June and July, as documented in the Medication Administration Record (MAR). The facility's records show that the medication was delivered by the pharmacy, but several scheduled doses were not given on both morning and evening shifts across multiple dates. The Director of Nursing (DON) acknowledged that there were issues obtaining a renewal prescription from the physician, and that the facility failed to notify the physician in a timely manner before the resident ran out of Ativan. The facility's medication administration policy requires staff to call the pharmacy and notify the physician if a medication is not available, and to report any missed doses as soon as practical. Despite these policies, the resident's medication was not administered as ordered due to delays in obtaining the necessary prescription renewal, resulting in missed doses.