Failure to Administer Discharge-Ordered Psychotropic Medication After Readmission
Penalty
Summary
The facility failed to provide necessary care and services in accordance with a resident's goals for care and professional standards of practice. Specifically, upon readmission from a behavioral hospital, a resident with diagnoses including major depressive disorder, anxiety disorder, and cannabis use disorder did not receive an order for Divalproex Sodium DRT 250 mg, which was prescribed at discharge from the hospital for mood stabilization. Review of the resident's medical record and physician's orders confirmed the absence of this medication order. Interviews with facility staff, including a psychiatric nurse practitioner and the assistant director of nursing, confirmed that the psychotropic medication should have been ordered and administered upon the resident's return, but was not.