Failure to Notify Provider and Obtain Antianxiety Medication Resulting in Multiple Omitted Doses
Penalty
Summary
The deficiency involves the facility’s failure to notify the provider when an antianxiety medication was unavailable, resulting in multiple omitted doses for a resident with significant psychiatric diagnoses. The resident’s conditions included catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and the admission MDS showed a BIMS score of 10/15, indicating some memory recall deficits. The resident’s care plan documented that the resident was receiving antianxiety medication, with interventions to administer medications as ordered and update the provider of any concerns, complications, or changes in condition. A physician’s order directed lorazepam 0.5 mg by mouth three times daily for restlessness and catatonia, and later an order changed the lorazepam to 0.5 mg four times daily. Review of the MAR showed that lorazepam doses were not administered on multiple occasions because the medication was unavailable. On one date, two scheduled doses were omitted due to unavailability, with no documentation in the eMAR notes that the provider was notified. On subsequent dates, six additional lorazepam doses were omitted for the same reason, and the eMAR notes only indicated that the medication was not available and was on order, without any indication that the provider was notified. The psychiatric APRN stated she was not aware of any missed lorazepam doses and that a provider should have been notified, and the Regional Nurse similarly stated that a provider should have been notified for all missed doses and that the pharmacy should have been contacted for STAT delivery. The facility’s Medication Administration policy required that when medications are unavailable, the physician be notified immediately, the resident or responsible party be informed, the pharmacy or alternative suppliers be checked to expedite delivery, all actions be documented in the medical record, and the supervisor be notified, but the documentation reviewed did not show that these steps occurred.
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