Failure to Provide Ordered Psychotropic Medications at Admission
Penalty
Summary
The facility failed to ensure that a newly admitted resident’s ordered psychotropic medications were available and administered as scheduled upon admission. The resident, who had diagnoses including dementia with agitation and anxiety, was discharged from the hospital with orders for Risperidone 0.5 mg tablets (three tablets once daily, next dose due at 4:00 p.m.) and Trazodone 50 mg at bedtime (next dose due at bedtime). Review of the February medication administration record showed that neither the 4:00 p.m. dose of Risperidone nor the bedtime dose of Trazodone were given on the day of admission, and both medications were first administered the following day. The nurse admission note documented that shortly after arrival the resident was confused, combative, refused to wait for physical therapy, refused staff direction, entered the roommate’s area, moved items, and made contact with the roommate, with verbal redirection failing and the resident striking staff. A later nursing note the same evening documented that the resident had to be temporarily moved to another room because he and his roommate were screaming at each other, and that the resident was found in another resident’s room and remained combative with redirection. In an interview, the LPN on duty at admission stated that the resident’s discharge medications, including the scheduled Risperidone, were not available for administration when the resident arrived and were not available until the resident’s second day in the facility. The LPN reported that an emergency behavior medication was administered with little to no effect while the resident was having behaviors and was difficult to redirect. The facility’s Pharmacy Services policy stated that the facility would provide pharmaceutical services and procedures to assure accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet each resident’s needs.
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