Failure to Administer Ordered Anxiety Medication Due to Communication and Order Processing Breakdown
Penalty
Summary
A deficiency occurred when a resident with Parkinson's Disease and anxiety was admitted to the facility with a physician's order for alprazolam (Xanax) 0.25 mg to be given every 12 hours as needed for anxiety. Despite this order, the medication was never administered during the resident's stay. Review of the Medication Administration Record confirmed that alprazolam was not given, and pharmacy records indicated that the prescription was never filled because the pharmacy did not receive a valid prescription from the physician. The pharmacy attempted to contact the physician multiple times without success, and there were no notes indicating that facility nurses called the pharmacy about the medication. Staff interviews revealed confusion and lack of communication regarding the medication order. The LPN who admitted the resident stated that the night shift nurse was supposed to complete the admission process and was unsure if the medication was ordered or filled. The LPN also noted that during the weekend in question, staff were unable to reach the nurse practitioner or physicians, which was unusual and led to a post-incident meeting. The DON, who was not employed at the time, confirmed that alprazolam was available in the facility's starter supply and could have been administered with proper authorization, but could not explain why the medication was not filled or administered. The facility's policy required medications to be dispensed only upon receipt of a clear, complete order signed by an authorized prescriber. In this case, the lack of a valid prescription and the inability to contact the prescriber resulted in the resident not receiving the ordered medication for anxiety. The situation was further complicated by family involvement, visitor disruptions, and the resident's observable anxiety symptoms, but the core issue remained the failure to ensure the resident was free from significant medication errors due to breakdowns in communication and order processing.