Failure to Follow Physician Orders for Seroquel Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not properly following physician orders for Seroquel for one resident. The resident was admitted with dementia with behavioral disturbances and major depressive disorder and had physician orders for Seroquel 50 mg by mouth twice daily starting 12/20/2025 and Seroquel 25 mg by mouth at bedtime starting 12/19/2025. There was also a physician order to re-evaluate the Seroquel orders with the provider on 1/2/2026. The January 2026 MAR showed that this re-evaluation order was signed off as completed by an LPN, indicating the medications were re-evaluated with the provider, but progress notes contained no evidence that such a re-evaluation occurred. During an interview, the LPN stated she had signed that she re-evaluated the Seroquel order with the provider but acknowledged that she had not done so. She also revealed that when the Seroquel orders were initially entered, they were entered for only 14 days. The January 2026 MAR showed that the last administration of the twice-daily Seroquel was on 1/2/2026 at 1:00 PM and the last administration of the bedtime Seroquel was on 1/1/2026, after which both orders were no longer in place. The same Seroquel orders were not re-entered until 1/10/2026 and 1/11/2026, resulting in the resident not receiving Seroquel as ordered for a total of 8 days. The DON acknowledged that the Seroquel orders had initially been entered for only 14 days and that, upon later review, the orders were found to be no longer in place.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.