Failure to Administer Medications as Prescribed by Nurse Practitioner
Penalty
Summary
The facility failed to ensure that a resident received medications as prescribed by a nurse practitioner, resulting in the administration of unnecessary drugs. Specifically, a nurse practitioner ordered a reduction in the resident's Seroquel dosage from 50mg to 25mg at bedtime and the initiation of Trazodone 50mg at bedtime. However, the Medication Administration Record (MAR) showed that the resident continued to receive Seroquel 50mg at bedtime for three days following the new order, and Trazodone was not added to the MAR, resulting in missed doses. The resident was prescribed these medications for dementia and related symptoms. The Director of Nursing (DON) acknowledged being aware of the new orders but instructed the Assistant Director of Nursing (ADON) to hold off on implementing any psychotropic medication changes while the DON was off duty. The ADON confirmed that they followed the DON's instructions and placed the orders in a folder for the DON to address upon return. As a result, the medication changes were not implemented before the resident was discharged from the facility. The DON later stated that it was probably not in the best interest of the resident to delay the implementation of these orders.