Failure to Reconcile and Administer Antipsychotic Medication on Readmission
Penalty
Summary
The deficiency involves the facility’s failure to accurately reconcile and continue an antipsychotic medication upon a resident’s readmission. The resident had diagnoses including major depressive disorder, generalized anxiety disorder, and other specified persistent mood disorders, and was discharged from the hospital with an active order for Lurasidone (Latuda) 20 mg to be given orally with supper. On readmission, the hospital discharge medication list clearly showed this Latuda order, but the facility’s electronic medical record and Order Summary Report for the readmission did not include Latuda, and the admission progress note section for medication reconciliation indicated there were no medications recommended by the hospital. As a result, the Latuda order was not entered into the physician orders on readmission and was not administered on the first two days after the resident returned. The medication was not started at the facility until two days after readmission, when it was initiated based on the hospital discharge paperwork. Interviews revealed that the DON expected the admitting nurse to call the physician, verify medications from the hospital discharge paperwork, review readmit medications, obtain new orders, and document any changes, but this process did not occur correctly for this resident’s Latuda order. An interview with the resident’s psychiatrist confirmed that he was not notified that the resident had missed two days of the antipsychotic medication and that it was important for medications to be administered as ordered. The facility’s medication reconciliation policy required reviewing hospital medication orders, noting any that needed clarification, and reviewing all medications with the physician when obtaining admission orders, as well as reviewing medications when residents return from ER visits or physician appointments, but this process was not followed for the Latuda prescription in this case.
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.