Failure to Ensure Drug Regimens Were Free from Unnecessary Medications and Lacked Proper Monitoring
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary medications for two residents. For one resident, there was no appropriate diagnosis entered for the orders of Risperidone (an antipsychotic) and Divalproex (an anticonvulsant), despite these medications being prescribed. The pharmacy consultant had flagged the Risperidone as unnecessary for anxiety and requested its discontinuation, but the medication remained ordered without the correct diagnosis documented in the electronic medical record. The Director of Nursing (DON) acknowledged that during a transition between electronic medical record systems, some diagnoses did not transfer over and had to be manually entered, resulting in missing or incorrect documentation for these medications. For another resident, the facility did not ensure appropriate monitoring for side effects of Oxcarbazepine, which was prescribed for depression. Although the pharmacy consultant requested side effect monitoring for this medication, the monitoring order in the record was for an antidepressant, not specifically for Oxcarbazepine. The Assistant Director of Nursing (ADON) confirmed that the medication was being used for depression and not as an anticonvulsant, but the side effect monitoring was not correctly aligned with the medication’s use. The DON stated that she expected correct diagnoses to be associated with medications and for proper side effect monitoring to be conducted, but this was not consistently done.