Failure to Discontinue Unnecessary Antipsychotic Medication After Physician Order
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. Specifically, an order to discontinue an as-needed (PRN) antipsychotic medication, Olanzapine 2.5 mg, was signed by the Medical Director following a pharmacy medication regimen review. Despite this, the PRN order for Olanzapine remained active in the resident's record, and doses were administered after the discontinuation order was given. The resident involved was an older adult male with diagnoses including moderate dementia with behavioral disturbance, hypertension, and vitamin D deficiency. His care plan included the use of antipsychotic medication for behaviors and agitation, with monitoring for side effects and effectiveness. The medication administration record showed that the resident received PRN doses of Olanzapine after the discontinuation was ordered, and there was no documentation that the order to discontinue was implemented in a timely manner. Interviews with facility staff revealed a lack of clarity and follow-through regarding responsibility for executing pharmacy recommendations and physician orders. The Regional Compliance Nurse, Administrator, DON, and Pharmacy Consultant each described gaps in communication and execution of the discontinuation order. Facility policy required that physician orders be reviewed and entered into the electronic health record, but this process was not completed as required, resulting in the resident receiving unnecessary medication.