Failure to Provide Complete Prescribed Medication Taper
Penalty
Summary
A deficiency occurred when a resident with diagnoses of anxiety disorder, major depressive disorder, and ADHD did not receive the full provider-ordered taper of Venlafaxine during a cross-taper process to another antidepressant. The facility failed to obtain and administer the complete medication regimen as ordered, resulting in an unintended interruption of therapy. Record review showed that the resident did not receive Venlafaxine for a period of several days, and this lapse was due to the pharmacy only providing the first week of the taper and failing to supply the second week because of insurance-related issues. The facility did not ensure the medication was available or administered as prescribed. Interviews with the DON confirmed that the resident went approximately one week without the prescribed medication, leading to increased anxiety and distress. The DON acknowledged that the facility is responsible for ensuring residents receive all prescribed medications regardless of insurance or pharmacy barriers. The resident's medical doctor and psychiatric provider both confirmed they were not notified in a timely manner about the missed doses, and the psychiatric provider noted the resident experienced emotional distress and physical symptoms during the period without medication.