Failure to Communicate Discontinued Medication Order Led to Continued Administration
Penalty
Summary
The facility failed to ensure that a resident's discontinued medication order was properly communicated to both the resident's school and the contracted pharmacy, resulting in the administration of a discontinued medication. The process breakdown began when a physician discontinued the resident's Aripiprazole order, but the required school forms and notifications were not completed or sent. The Resident Education Nurse Coordinator verbally communicated the discontinuation to the school but did not follow the established process of completing and faxing or emailing the appropriate forms. As a result, the school and pharmacy were not formally notified of the medication change. The resident, who had diagnoses including autism and spastic quadriplegic cerebral palsy, was admitted with behavioral challenges such as refusals of care and physical behaviors. The resident's Aripiprazole order was initially communicated to the school and pharmacy, and the medication was delivered to the school after the order had already been discontinued. Due to the lack of formal written notification, the school nurse continued to administer Aripiprazole to the resident for eight days after the discontinuation, only becoming aware of the error following the resident's hospitalization for a change in mental status. Interviews with facility staff and the contracted pharmacy confirmed that the pharmacy and school did not receive timely or proper notification of the medication discontinuation. The facility's policy required daily order reviews and written communication of medication changes, but this process was not followed. The deficiency was identified through a root cause analysis, which found that the medication-order double-check process failed and that communication lapses led to the continued administration of a discontinued medication.