Failure to Obtain and Administer Ordered Antipsychotic Medication Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that licensed nurses followed up with the contracted pharmacy regarding a physician's order for Seroquel 25 mg three times daily for a resident with diagnoses including bipolar disorder, Alzheimer's disease, schizophrenia, and Parkinson's disease. The order was written to manage the resident's aggressive behavior, but the medication was not obtained or administered for eight days. Documentation in the Medication Administration Record (MAR) repeatedly indicated that the medication was not available, and progress notes showed ongoing delays attributed to awaiting pharmacy delivery. The pharmacy confirmed that no medication request was received for the order, and the medication was not delivered until eight days after the order was written. During this period, the resident did not receive the prescribed Seroquel, which was intended to manage symptoms of aggression and angry outbursts. On the eighth day without the medication, the resident exhibited aggressive behavior by pushing another resident, resulting in the second resident falling and sustaining a 1.0-inch laceration to the back of the head. The injured resident required evaluation and treatment at a general acute care hospital, where two staples were placed to close the wound. Interviews with staff and review of records confirmed that the medication omission was not promptly addressed, and the pharmacy was not contacted in a timely manner to resolve the issue. The facility's policy on medication errors defines omission of a vital medication as a medication error and requires assessment, documentation, and reporting to the physician and pharmacy. Despite this policy, the omission persisted for eight days, and the resident's care plan, which included administration of psychotropic medications as ordered, was not followed. The Director of Nursing acknowledged that staff failed to ensure the medication was obtained and administered as ordered, and that this failure could have contributed to the aggressive incident and resulting injury.