Failure to Administer Prescribed Medication and Notify Provider
Penalty
Summary
The facility failed to provide services that meet professional standards of quality for one resident by not administering the medication Ingrezza (Valbenazine Tosylate), prescribed for tardive dyskinesia, as ordered by the provider. The medication was missed on multiple occasions, as documented in the Medication Administration Record (MAR), with no evidence of administration or appropriate documentation for the missed doses. Additionally, there was a period when the medication was discontinued by facility staff and administered without a current physician order, contrary to the provider's intent and without proper communication or documentation. The resident involved had complex medical needs, including a brain tumor, Parkinson's Disease, epilepsy, drug-induced subacute dyskinesia, and a history of falls. The provider's progress notes indicated that the resident experienced increased involuntary movements and falls when the medication was not administered as prescribed. Despite these clinical changes, there was no documentation in the medical record explaining the missed doses or evidence that the provider was notified about the medication not being given on at least ten occasions. Interviews with nursing staff and the nurse practitioner revealed a lack of clarity regarding the medication orders and administration. The nurse practitioner stated that she had not discontinued the medication and was unaware of the extent of missed doses, indicating a breakdown in communication and failure to follow facility policy and professional standards regarding medication administration and provider notification.