Failure to Evaluate Ongoing Need for Antifungal Medication
Penalty
Summary
A deficiency was identified when a resident with a history of chronic abdominal wall abscess was found to have an active order for Fluconazole 200 mg weekly, which had been in place since June 2024. Review of the resident's medical record and monthly Medication Administration Records confirmed ongoing administration of the antifungal medication, but there was no documentation indicating the clinical rationale for its continued use. Pharmacy medication regimen reviews from December 2024 onward did not address the necessity of the Fluconazole, and provider progress notes did not document a reason for maintaining the order. Interviews with nursing staff and the Director of Nursing Services revealed uncertainty regarding the indication for the medication, with staff speculating it might be for prophylactic use but unable to provide supporting documentation. The order was listed as being for "infection," but this was not substantiated in the resident's records. The lack of documented evaluation or justification for the ongoing use of Fluconazole resulted in the resident receiving a potentially unnecessary medication.