Failure to Follow Discharge Orders Led to Unnecessary Psychotropic Medication Administration
Penalty
Summary
Facility staff failed to ensure that unnecessary psychotropic medications were not administered to a resident by using the at-home medication list for admission orders instead of following the physician-verified hospital discharge summary. As a result, the resident received Amitriptyline 10 mg and Trazodone 100 mg at bedtime, which were not prescribed upon discharge from the hospital. Multiple staff interviews confirmed that the at-home medication list was incorrectly used, and the hospital discharge summary, which should have guided medication administration, was not followed. The clinical record review revealed that the resident had a history of delirium in the hospital, which had resolved by the time of discharge. Despite this, the facility continued to monitor for delirium and administered the unnecessary psychotropic medications. The resident's son repeatedly requested that these medications be discontinued due to concerns about delirium, and the nurse practitioner documented her intent to discontinue them. However, the medications were only held temporarily and then restarted, with no evidence that the discontinuation was completed as requested. Facility documentation and policy reviews indicated that medications are to be administered according to written prescriber orders and that discharge orders from the hospital should be reviewed and approved by the attending physician. Despite these policies, the facility did not have a specific policy related to psychotropic medication use, and the process for verifying and following discharge orders was not properly implemented. This resulted in the resident receiving medications that were not part of the discharge plan, contrary to both facility policy and the expressed wishes of the resident's representative.