Failure to Ensure Timely Acquisition and Administration of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of medication for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including Alzheimer's disease, dementia with agitation, and anxiety disorder. The resident had physician orders for two different dosages of quetiapine (Seroquel), an antipsychotic medication, to be administered at specific times. Documentation in the Medication Administration Records (MARs) indicated that the medication was on order on one date, but was marked as administered on subsequent dates. However, when a nurse was questioned about the administration and asked to check the medication cart, it was found that there was no medication card (blister pack) for the Seroquel, and the nurse could not confirm whether the medication had been administered or pulled from the back-up supply. Further review by facility leadership and pharmacy records revealed that there was no documentation of Seroquel being pulled from the back-up supply for the month in question, and the medication card showed that the Seroquel was not delivered until several days after it was ordered. There was also a lack of documentation for the relevant period and no evidence that the medication was available or administered as ordered. This sequence of events demonstrates a failure in the facility's process for ensuring the timely acquisition and administration of necessary medications to meet the needs of the resident.