Failure to Ensure Medication Regimen Free from Unnecessary Drugs Due to Incomplete Diclofenac Order
Penalty
Summary
A deficiency was identified when a resident with diagnoses including bipolar disorder, depression, opioid dependence, and a healing femur fracture was prescribed diclofenac sodium external gel 1% for pain management. The physician's order for this medication lacked a specified dose and did not indicate the exact body location for application, contrary to established dosage guidelines. The order also included application to areas such as the back and legs, which are not recommended for diclofenac gel according to the Physician's Desk Reference. The pharmacist's admission medication regimen reviews on two separate occasions failed to identify these omissions and inappropriate indications in the order. The resident received the diclofenac gel 127 times over a period of approximately one month, with the medication being applied to multiple body areas as per the incomplete order. During an interview, the DON confirmed that the pharmacist's reviews should have identified the lack of a specified dose and inappropriate application sites. The failure to ensure the medication order was complete and appropriate resulted in the resident receiving unnecessary drugs, as the medication regimen was not free from unnecessary medications as required.