Failure to Administer Ordered Antipsychotic Medication Due to Unavailability and Lack of Provider Notification
Penalty
Summary
The facility failed to provide Invega Sustenna, a long-acting antipsychotic medication, to a resident diagnosed with schizoaffective disorder, bipolar type, for three consecutive months. The resident was admitted with significant mental health diagnoses and had a physician's order for monthly administration of Invega Sustenna. Review of the Medication Administration Record (MAR) showed that the medication was not administered in May, June, or July, with documentation indicating the medication was either on hold, not available, or not delivered. Progress notes and MAR entries confirmed the medication was not given, and there was a lack of documentation that the provider was notified or that further instructions were obtained after the medication was found to be unavailable. Interviews with the Mental Health Case Manager and the Director of Nursing revealed that nursing staff did not follow up with the provider for further direction or document any such communication when the medication was unavailable. The facility's policy on administering medications required medications to be given according to prescriber orders but did not provide guidance for situations when ordered medications were unavailable. The Director of Nursing stated that nurses were expected to notify her if a medication was not available and to obtain further instructions from the provider, which did not occur in this case.