Failure to Discontinue Medication as Ordered
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency occurred when a resident continued to receive an antiulcer medication at a total daily dosage of 60 mg, despite the attending provider's order to reduce the dose to 20 mg daily. The pharmacist had recommended a dose reduction after reviewing the resident's medication regimen, and the provider issued a new order to decrease the medication. However, review of the Medication Administration Record (MAR) showed that the resident was administered both the original 40 mg dose and the new 20 mg dose daily, rather than discontinuing the higher dose as ordered. The DON confirmed during interview that the staff failed to discontinue the 40 mg dose, resulting in a medication error.