F0755

D

Failure to Provide and Document Ordered Antipsychotic Medication

Dillsboro, Indiana Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a prescribed antipsychotic medication was available and administered as ordered for one resident. The resident had severe cognitive impairment with diagnoses including Alzheimer’s disease and anxiety, and had an open-ended physician order for Risperdal 2 ml IM every 14 days for delusions starting on 02/24/2026. Review of the EMAR for February and March 2026 showed the resident did not receive the ordered Risperdal doses on 02/24/2026 and 03/24/2026. Progress notes documented that on 02/24/2026 the medication was not available at the pharmacy and on 03/24/2026 the medication was not in the facility. The Emergency Drug Kit list did not include injectable Risperdal.

Interviews and policy review further described the processes that should have been followed when medications were unavailable. An LPN stated that if a medication was not available, staff would check the EDK, contact the pharmacy or a local pharmacy, mark the medication as not available in the EMAR, call the physician, and document in a progress note. The DON stated that when medications were not available, staff were to check the EDK, order from the pharmacy, and notify the provider if a dose was missed, typically by verbal communication without documentation in the clinical record. The facility’s “Out of Stock Medications” policy required contacting alternative suppliers, notifying the physician when an ordered medication was not available, and allowing the physician to decide whether to hold or change the medication. The clinical record for this resident lacked documentation that the physician was notified when the resident did not receive the ordered Risperdal doses on 02/24/2026 and 03/24/2026.