Failure to Discontinue Unnecessary Medication After Provider Approval
Penalty
Summary
A resident with diagnoses including dementia and chronic kidney disease was admitted to the facility and was prescribed Loratadine, an antihistamine medication. The Consultant Pharmacist made repeated recommendations to discontinue Loratadine, which were communicated to both the provider and nursing staff over several months. On 10/8/24, the provider agreed with the recommendation to discontinue the medication, and this agreement was documented in the resident's clinical record. Despite this, the resident continued to receive scheduled doses of Loratadine for over three months, as indicated by the Medication Administration Records, until the medication was finally discontinued on 2/4/25. The Director of Nursing (DON) confirmed during interviews that the process for handling Consultant Pharmacist recommendations involved emailing the Unit Manager, printing the recommendations, and placing them in the Provider's Communication Book. The DON stated that nursing staff were expected to check the communication book every shift and implement provider-approved orders immediately. However, the DON was unable to explain why the Loratadine was not discontinued as ordered, acknowledging that the medication continued to be administered unnecessarily after the provider had agreed to stop it.