Failure to Implement Physician-Ordered Antidepressant Dose Reduction
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, diabetes, heart disease, depression, and anxiety continued to receive an unnecessary dose of Remeron (mirtazapine), an antidepressant medication, despite a signed physician order to decrease the dose. The pharmacy had recommended, and the medical director agreed, to reduce the resident's Remeron from 22.5mg to 15mg nightly. However, the medication administration record showed that the resident continued to receive the higher dose for an extended period after the order was signed. The failure was attributed to a breakdown in the facility's process for implementing pharmacy recommendations and physician orders. The DON stated that the charge nurse is responsible for updating orders and providing documentation for follow-up, but in this case, the signed order to decrease the medication was not properly communicated or acted upon. As a result, the resident continued to receive a higher dose of medication than was necessary, contrary to facility policy and regulatory requirements.