F0684

E

Failure to Recognize and Respond to Medication-Related Changes in Condition for Two Residents

Watsontown, Pennsylvania Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to appropriately respond to changes in condition for two residents. For one resident with hypertension, dementia, and a history of stroke, the clinical record showed a long-standing order for fluoxetine that was to be increased from 30 mg to 40 mg daily per a psychiatry note. Instead, a physician order was entered for duloxetine 40 mg daily, and the resident received duloxetine for three consecutive days. During this period, the resident was noted to have bloody tissues, a small blood clot on the tray table, and dried blood around the nares. Subsequent documentation identified that the resident had received the incorrect medication (duloxetine 40 mg for three doses), and the resident later developed active epistaxis with large blood clots, intermittent nosebleeds with increasing frequency and amount, and complaints of weakness and dizziness.

Staff interviews revealed that multiple LPNs were aware that nosebleeds and excessive bleeding can be adverse effects of anticoagulant medications, but several of them were unaware that duloxetine carries a risk of abnormal or excessive bleeding. One LPN stated that she and other staff only learned about duloxetine’s bleeding risk after the resident was hospitalized and they looked up the side effects. The report notes that duloxetine’s prescribing information includes abnormal bleeding in the Warnings and Precautions section, and the facility’s change in condition policy requires notification of the resident, physician, and representative of changes in medical or mental status. The findings show that staff knowledge of duloxetine’s side effects was limited primarily to behavioral effects, and the facility did not appropriately recognize or respond to the resident’s change in condition in the context of the incorrect medication administration and subsequent bleeding episodes.

For the second resident, who had diagnoses including anemia, urinary tract infection, and a pressure ulcer, staff discovered a bottle of mixed pills in the room and were unaware what the resident had taken. A CNA reported that the resident had slurred speech, was leaning to the side, and had pinpoint pupils. All medications in the room were removed and given to the RN supervisor, and the resident was educated that medications could not be kept at the bedside. Despite the resident’s neurologic and possible intoxication-type symptoms and the presence of multiple mixed medications including Tylenol 3, the RN supervisor directed that Creon be given and later provided pain medication, and the resident also received tramadol and gabapentin. Progress notes documented the perception that the resident may have independently taken Tylenol 3 and appeared to be under the influence, but the record did not show that the possibility of narcotic ingestion was addressed with the provider or that the provider was notified of possible consumption of narcotic pain medication in addition to the administered tramadol and gabapentin until the family voiced concerns about increased altered mental status and requested transfer to the ED.