Failure to Administer Ordered Anti-Anxiety Medication as Prescribed
Penalty
Summary
Surveyors identified a deficiency in ensuring residents are free from significant medication errors when a resident with COPD, heart failure, and hypertension did not receive a prescribed anti-anxiety medication as ordered. The facility’s policy defined a medication error to include omission of an ordered drug. The resident was admitted with a physician’s order for Xanax 0.5 mg three times daily for anxiety, but review of the MAR showed the medication was not administered as ordered. A provider note documented that upon initial admission the resident did not have their medications at the facility while awaiting pharmacy, and the resident was sent back to the hospital the same evening with crushing chest pain and tachycardia, treated, and then returned to the facility later that night. On subsequent observation, the resident was noted to be complaining of nausea and feeling shaky. During an interview, an RN stated that the resident had not received the ordered Xanax as prescribed and expressed the belief that the resident was experiencing withdrawal symptoms after a long history of receiving Xanax three times daily. The resident reported having received the Xanax only twice since being at the facility. The DON later confirmed that the facility failed to ensure residents were free from significant medication errors for this resident.
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