Failure to Ensure Drug Regimens Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications in two separate cases. In the first case, a resident with a history of smoking and nicotine dependence was prescribed a nicotine transdermal patch. Despite repeated recommendations from the consulting pharmacist and CDC guidelines to gradually decrease and discontinue the nicotine patch, especially if the resident continued to smoke, the facility did not implement a dose reduction. The resident was documented as both currently smoking and as having not smoked for a period, with conflicting reports from staff and the resident. The pharmacist’s recommendations to decrease the patch were acknowledged by the provider, but the resident refused the reduction, and the facility did not pursue alternative strategies or document a clear plan for dose reduction, as required by facility policy. In the second case, the facility failed to monitor, assess, and clarify an antibiotic order for a resident with severe cognitive impairment and multiple medical diagnoses, including a history of traumatic brain injury and ocular issues. The resident was prescribed moxifloxacin ophthalmic solution for bacterial conjunctivitis and later for other eye conditions, but the order lacked a specified end date. Review of the resident’s medical records showed ongoing administration of the antibiotic without clear documentation of the duration or ongoing need, and there was no evidence of regular assessment for effectiveness or side effects. Staff interviews revealed uncertainty about the resident’s follow-up appointments and the necessity of continuing the antibiotic, and the facility’s own policy required antibiotic orders to include a stop date or duration, which was not followed in this case. Both deficiencies were identified through interviews, document reviews, and observations, which showed a lack of adherence to facility policies and best practices regarding medication management. The facility did not ensure that medications were regularly reviewed for necessity, that dose reductions were attempted as appropriate, or that antibiotic stewardship protocols were followed, resulting in residents receiving medications without adequate justification or monitoring.