Excessive Tylenol Dosage Administered to Resident
Penalty
Summary
The facility failed to ensure sufficient nursing staff with the appropriate competencies and skills to provide safe nursing services, as evidenced by the case of a resident who received an excessive dosage of Tylenol. The resident, diagnosed with bilateral knee osteoarthritis and muscle weakness, was prescribed Tylenol 1000 mg every 8 hours by an Orthopaedic Surgery Specialist. However, the resident was already receiving Tylenol 8-hour oral tablet extended release three times a day, with a maximum dosage limit of 3 grams per 24 hours. This oversight led to the resident receiving over 15,000 mg of Tylenol over three days, significantly exceeding the safe dosage limit. The error occurred because the Registered Nurse entered the new Tylenol order without realizing the existing order, and the Certified Nurse Practitioner signed off on the consult without clarifying the total dosage. The Medication Administration Record showed that the resident received both the existing and new Tylenol orders simultaneously, leading to the excessive dosage. Interviews with staff confirmed that the resident should not have received more than 3000 mg per day due to potential liver damage, highlighting a failure in the facility's medication administration process.
Plan Of Correction
1. The facility cannot retroactively correct failure to ensure the physician reviews the resident's total program of care, including medications. Once Resident 1 was found to have incorrect orders, proper notifications were made, resident was placed on alert charting along with vital signs, labs were ordered to monitor liver function for side effects of additional Tylenol. DON/designee will reiterate and audit the chart checks which are to be done on 3rd shift. Each chart will have a check list that needs to be signed off by third shift LPN daily to ensure orders are correct and there are no duplicate orders. They are monitored by the nursing supervisors to ensure they are being completed. 24 hour report binders were implemented and are placed on each unit. These are to be filled out each shift and reviewed in the change of shift report. This ensures changes to medications/orders that may have happened on off shifts via on call are properly documented, placed in the chart, and the PCP will follow up the next day to ensure orders are correct. A new admission check list has been created by NPE, and will be brought to the next morning meeting after admission arrives to go over with clinical staff. This includes all BATCH orders which are ordered on admission, the residents after visit summary orders from the hospital to ensure their medications are appropriately dosed and correct. 2. DON/nursing designee will perform an initial audit on the past 30 days on residents who have gone to outside appointments/consults to ensure physician recommendations are properly placed in the provider binders for review on the appropriate order sheet. Initial audit will also include admissions the past 30 days to ensure there are no duplicate BATCH orders placed (which are most common medications with potential medication duplicates/errors). 3. DON/nursing designee will re-educate on chart checks, and explain the chart check process. Medical records will place charts in each chart for these to be signed off of. NPE is also educating staff on "second checks," meaning we get 2 LPN's to review orders and agree they are correct. This now ensures we have 3 steps in place to be ordered to check orders correctly. Nursing staff and providers will be educated to complete orders on the appropriate order sheet only, to avoid confusion. 4. DON/designee will perform weekly audits x4 weeks to ensure new admission checklist are being done on new admissions, medication administration reviews on new admissions to ensure BATCH orders are appropriately placed, and that the admission checklist was brought and completed to morning meeting for review. Audit will focus on new admissions for that week. 5. Results will be reported to QAPI for review and further recommendations if needed.