Failure to Ensure Proper Physician Order and Documentation for Antipsychotic Administration
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident, specifically regarding the administration of Haldol (an antipsychotic medication). A review of the resident's records showed that there was no physician's order for Haldol Decanoate, nor was there an indication for its use documented on the order. Despite this, progress notes indicated that a nurse practitioner had given a verbal order for Haldol for aggressive behavior, and a nurse documented administering the medication. However, the medication administration record (MAR) did not contain an order for Haldol, and the order lacked the required indication for use. The resident involved had a history of dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a traumatic subdural hemorrhage. The admission Minimum Data Set (MDS) indicated severe cognitive impairment, with no behavioral symptoms or indicators of psychosis, and the resident was not previously receiving an antipsychotic. The care plan was later updated to reflect the use of antipsychotic medication for agitation, but this was after the medication had already been administered without a proper order. Interviews with facility staff revealed that the medical director was not aware of the Haldol order and would not have prescribed it. Nursing staff acknowledged that all necessary checks, including consent, diagnosis, and documentation, were required before administering antipsychotics, and the Director of Nursing confirmed that the order was incomplete and not properly verified before administration. The facility's medication administration policy required verification of orders and documentation on the MAR, which was not followed in this instance.