Medication Reconciliation Error Leads to Significant Medication Error
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease was admitted to the facility and experienced significant medication errors due to inaccurate medication reconciliation. Upon admission, nursing staff incorrectly transcribed the resident's hospital discharge orders for Carbidopa-Levodopa, a medication critical for managing the resident's movement disorder. The hospital discharge summary specified that the resident should receive two tablets of both immediate release and extended release Carbidopa-Levodopa at specified times, but the orders entered into the facility's system only provided for one tablet of each formulation. As a result of this error, the resident received only half the prescribed dose of Carbidopa-Levodopa for multiple days. This discrepancy was identified after the resident reported symptoms to their representative, who then inquired about the medication regimen. Review of the Medication Administration Record confirmed that the resident had received the incorrect dosage on several occasions, both for the immediate release and extended release formulations. Interviews with facility staff, including the nurse responsible for the admission and the nursing supervisor, confirmed that the medication reconciliation process was not followed accurately. The nurse failed to correctly transcribe the hospital discharge medication list, and the error was not identified until after the resident had already received the incorrect dosages. The Director of Nursing acknowledged that the orders were entered incorrectly and that the resident was administered the wrong dose until the issue was corrected.