Failure to Ensure Proper Physician Review of Medication Orders on Admission
Penalty
Summary
Facility staff failed to ensure that a physician or appropriate practitioner thoroughly reviewed a resident's medication regimen upon admission. Specifically, a resident was prescribed amitriptyline for depression, despite the absence of a documented diagnosis of depression or delirium in the clinical record or hospital discharge summary. The nurse practitioner noted the son's request to discontinue antipsychotic medications, including amitriptyline, trazodone, and Seroquel, and intended to discontinue them, but did not complete the discontinuation process. The medications remained active from admission until the resident's discharge. Interviews with facility staff, including the MDS Coordinator and the nurse practitioner, revealed that the diagnosis of depression was incorrectly assigned based on assumptions rather than documented evidence. The nurse practitioner acknowledged that the diagnosis was not found in the hospital records and that the nursing staff had entered the diagnosis with the medication on admission, which she did not notice when signing off on the paperwork. Facility policy required that admission information and orders be reviewed and approved by the attending physician, and that the medical plan of care be reviewed at each visit, but this process was not properly followed in this case.