Medication Administration Error: Incorrect D3 Dosage
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice by not administering medications as per the physician's orders for a resident. Specifically, the deficiency involved the administration of Vitamin D3 to a resident, where the prescribed dose was 1000 IU daily, but the resident was given 2000 IU instead. This discrepancy was observed when an LPN was preparing to administer medications and realized the need to clarify the order for D3. Despite the physician's order being for 1000 IU, the medication available and administered was 2000 IU. Further investigation revealed that the medication administration record indicated compliance with the physician's orders, but the physical medication cards showed otherwise. One card of D3 2000 IU had 29 tablets removed, while another card remained untouched. Interviews with the LPNs involved confirmed that the incorrect dose was administered on multiple occasions. The Director of Nursing acknowledged awareness of the issue and expressed the expectation that nurses follow the physician's orders.
Plan Of Correction
1. Physician order was clarified and updated to reflect 2000 units, consistent with the original dosage on. The dosage was administered on MARs audited facility-wide for compliance with physician orders initiated and completed. 2. Medication administration training initiated for licensed nurses; projected completion date. 3. Random audits twice weekly for 30 days led by DON or designee; pharmacy consultant monthly reviews, change in pharmacy services provider beginning. Reviewed in QAPI. 4. Report to QA committee will continue monthly for recommendations and or revisions. Completion Date: