Failure to Administer Physician-Ordered Medications Due to Unauthorized Staff Instructions
Penalty
Summary
The facility failed to ensure that physician-ordered medications were prescribed and administered upon admission for two residents. One resident with multiple mental health diagnoses, including anxiety disorder, major depressive disorder, bipolar disorder, and panic disorder, was admitted with orders for Austedo XR and Vraylar to treat depression. Despite these orders, the medications were not administered, as indicated by the Medication Administration Record and confirmed by the pharmacist, who received the medication list with a handwritten note stating 'do not send.' Another resident with diabetes mellitus and diabetic polyneuropathy was admitted with a prescription for Ozempic to manage diabetes. The hospital discharge summary included a handwritten note stating 'Not while at facility,' and the medication was not administered during the resident's stay. The pharmacist did not fill the prescription due to this note and did not complete a high-cost medication form, as is the facility's protocol for medications exceeding a $200 threshold. No alternative diabetes medication was prescribed or administered to this resident during their stay. Interviews with facility staff, pharmacy staff, and the nurse practitioner revealed that facility staff had written unauthorized notes on medication lists sent to the pharmacy, instructing not to send certain medications. The nurse practitioner and administrative staff were unaware of these actions and stated that facility staff do not have the authority to alter or withhold physician-ordered medications. The facility did not have a formal policy addressing this practice, and the pharmacy did not question or report the handwritten instructions, resulting in residents not receiving prescribed medications.