Incorrect Antidepressant Ordered and Administered to Resident
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when an incorrect antidepressant was ordered and administered. A resident with diagnoses including hypertension, dementia, and a history of stroke had been on fluoxetine (Prozac) since 11/19/22, with continuous reorders through early 2026. A psychiatry progress note dated 1/26/26 documented a recommendation to increase the resident’s fluoxetine dose from 30 mg daily to 40 mg daily for major depressive disorder, and a progress note on 1/29/26 reiterated this recommendation. However, a physician’s order dated 1/30/26 was entered for duloxetine 40 mg once daily instead of fluoxetine. Review of the MARs for January and February 2026 showed that the resident received duloxetine on three consecutive days (1/30/26, 1/31/26, and 2/1/26). A progress note dated 2/2/26 documented that the resident had received the incorrect medication, duloxetine 40 mg, for three doses. The facility’s Medication Error Reporting policy required that medication errors be documented and reported to identify causes and develop prevention strategies. During interviews, the DON confirmed that duloxetine was inadvertently ordered in place of fluoxetine, and the Nursing Home Administrator and DON acknowledged that the facility failed to ensure residents were free of significant medication errors for one of five residents reviewed.
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