Failure to Administer Ordered Antipsychotic Medication Resulting in Resident Altercation
Penalty
Summary
The facility failed to ensure that Seroquel 25 mg, an antipsychotic medication, was obtained, available, and administered as ordered for a resident with multiple psychiatric and neurological diagnoses, including bipolar disorder, Alzheimer's disease, schizophrenia, and Parkinson's disease. Despite a physician's order for Seroquel 25 mg three times daily starting on 11/24/2025, the medication was not requested from the pharmacy until 12/1/2025 and was not received by the facility until 12/2/2025. As a result, the resident missed eight consecutive days of the prescribed medication. During this period without the ordered antipsychotic, the resident, who had severely impaired cognitive skills and required assistance with daily living activities, was involved in a resident-to-resident altercation that resulted in injury to another resident. The DON confirmed that nursing staff did not ensure timely procurement and administration of the medication, and acknowledged that the absence of Seroquel could have contributed to the escalation in the resident's behavior. Facility policy defined the omission of a prescribed medication as a medication error.