F0756

D

Failure to Timely Implement Pharmacy and Physician Discontinuation of PRN Hydroxyzine

Canton, Ohio Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely implementation of pharmacy recommendations to discontinue a medication after physician approval. A resident admitted with diagnoses including a displaced right humerus fracture, gait and mobility abnormalities, type II diabetes mellitus, morbid obesity, and chronic kidney disease had a physician order dated 01/27/26 for Hydroxyzine Pamoate 25 mg to be given orally once daily as needed. The five-day admission MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and documented that the resident was receiving a diuretic, opioid, antiplatelet, and antidepressant. On 02/16/26, the consulting pharmacy recommended discontinuation of Hydroxyzine Pamoate 25 mg, and on 02/20/26 the physician reviewed and agreed with this recommendation, signing to discontinue the medication.

Despite the physician’s discontinuation decision, review of the February and March 2026 MARs showed that the Hydroxyzine Pamoate order remained active and the medication continued to be administered. The MAR for February 2026 documented administration of Hydroxyzine Pamoate 25 mg on 02/25/26, and the March 2026 MAR documented administrations on 03/06/26 and 03/11/26. The order itself was not discontinued until 03/16/26. During an interview on 03/17/26, the Regional Nurse confirmed that the pharmacy recommendation to discontinue the medication was made on 02/16/26, the physician signed to discontinue it on 02/20/26, but the medication continued to be given on the above dates and the order remained in place until mid-March. Facility policy on medication administration stated that medications are to be administered in accordance with prescriber orders, which did not occur in this case.