Failure to Ensure Adequate Indication and Review for Concurrent Medication Orders
Penalty
Summary
The facility failed to ensure that adequate indication for medication was provided for one resident. Upon admission, the resident, who was alert, oriented, and able to make needs known, was prescribed Diclofenac and Eliquis. The facility's pharmacy generated a potential drug interaction report noting that concurrent use of these medications should be approached with caution. Despite this, the resident was administered Diclofenac on the first night and subsequently refused further doses due to concerns about medication interactions. Nursing documentation confirmed the resident's refusal and concern about the medication combination. Staff interviews revealed that the pharmacy had notified the facility of the potential contraindication on the day of admission, but the facility did not notify the on-call provider or Medical Director to review or adjust the medication orders as recommended. This lack of timely provider notification and review led to the deficiency.