Failure to Implement Physician-Ordered Gradual Dose Reduction of Antipsychotic Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses of bipolar disorder and recurrent depressive disorders did not receive a physician-ordered gradual dose reduction of olanzapine, an antipsychotic medication. The physician had ordered the olanzapine dosage to be decreased from 20 mg daily to 15 mg daily, following a pharmacist's recommendation for a gradual dose reduction. However, the medication administration records and pill blister card review revealed that the resident continued to receive the higher 20 mg dose for 11 days after the order change. The error was discovered when it was noted that the first 15 mg dose was not administered until 12 days after the order was written. The Certified Medication Aide (CMA) responsible for administering the medication stated they were unaware of the dosage change and continued to give the previous 20 mg dose, failing to verify the current physician order against the medication card prior to administration. The Director of Nursing (DON) confirmed that the resident received the incorrect dosage for 11 days, as the CMA had not checked the updated order. The resident was moderately cognitively impaired, had no symptoms of depression or behaviors at the time, and had been receiving both antipsychotic and antidepressant medications.