Failure to Ensure Resident Was Free from Significant Medication Errors
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from significant medication errors related to the administration of Ingrezza (Valbenazine Tosylate), a medication prescribed for Tardive Dyskinesia (TD). The resident, who had a complex medical history including a brain tumor, Parkinson's Disease, epilepsy, drug-induced subacute dyskinesia, and a history of falls, was admitted in June 2024. The provider's progress notes consistently indicated that Ingrezza 80 mg via G-tube at bedtime was to be continued for significant TD, as involuntary movements were likely contributing to the resident's falls and the medication appeared to be beneficial. Review of the Medication Administration Records (MAR) for May and June 2025 revealed that the resident missed a total of ten doses of Ingrezza out of 47 opportunities. Specific dates were identified where the medication was either not administered, not initialed as given, or marked as not given without documented reasons or correlating progress notes. Additionally, there was a period where the medication order was discontinued without clear justification, and the provider stated that they had not discontinued the medication since it was restarted in May 2025. The DON and Regional Nurse Consultant confirmed that several doses were missed, some due to the medication being accidentally discontinued and others for reasons that required further research. Interviews with nursing staff and the provider revealed a lack of clarity regarding the medication's administration and order status. The nurse was unaware of the discontinuation and believed the medication should have been continued at bedtime. The provider confirmed the intent to continue the medication, and the DON acknowledged missed doses and accidental discontinuation. There was no documentation indicating that the provider had been notified of the missed doses, nor was there evidence explaining why the medication was not administered on the identified dates.