Failure to Administer Ordered Medication Due to Accidental Discontinuation
Penalty
Summary
A resident with severe cognitive impairment and diagnoses including non-Alzheimer's dementia, atrial fibrillation, and hypertension had a physician's order for Memantine 5 mg twice daily. The order was discontinued on 7/7/25 with a note referencing medications from home, but the resident did not receive the prescribed Memantine from 7/8/25 through 7/28/25. Documentation shows that the family notified the facility of the discontinuation, and the nurse confirmed the medication was stopped in error. The medication was not administered for approximately three weeks due to this accidental discontinuation, despite the physician's order requiring its administration. Facility policy requires that medications be provided in accordance with physician orders, which was not followed in this instance.