Failure to Notify MD of Missed Antidepressant Doses
Penalty
Summary
The facility failed to notify the Medical Director (MD) of missed doses of an antidepressant medication, Venlafaxine, for a resident diagnosed with anxiety disorder, major depressive disorder, and ADHD. The resident did not receive Venlafaxine for a period of seven days, as documented in the Medication Administration Record. During this time, the facility did not communicate the missed doses or the unavailability of the medication to the MD, despite the resident's ongoing mental health conditions and the prescribed medication schedule. The deficiency was confirmed through record review and interviews, which revealed that the DON acknowledged the MD was not informed of the missed doses, and the MD confirmed he was not notified until the second week of the missed medication. The resident subsequently experienced suicidal thoughts, which were documented in the provider's visit notes after the period without medication. The MD stated he would have taken steps to provide the medication sooner if he had been notified promptly.