Significant Medication Errors: Incorrect Dosing and Improper Administration of Depakote
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by incorrect medication dosing and improper medication administration practices. One resident was admitted with a hospital order for Divalproex (Depakote) 250 mg three times daily, but the facility entered and administered a lower dose of 125 mg three times daily for six days. This discrepancy was not accompanied by any documentation of a physician order change or justification in the medical record, despite facility policy requiring orders to match hospital discharge instructions unless otherwise directed by a provider. Additionally, staff failed to follow manufacturer and pharmacy recommendations regarding the administration of Depakote delayed release tablets. Multiple residents received their Depakote tablets crushed, despite clear labeling and manufacturer instructions stating that the medication should not be crushed. In one case, a resident who had difficulty swallowing and often refused medication was given crushed Depakote after a physician order was obtained to crush medications. However, the medication card was labeled "do not crush," and the staff did not have a do not crush list available. Another resident also received crushed Depakote due to dietary needs, with the medication administered in pudding. These actions resulted in at least one resident being hospitalized with a low therapeutic level of Depakote, as confirmed by hospital laboratory results. Interviews with staff, including the DON and pharmacist, confirmed that crushing delayed release Depakote is not recommended and can affect the medication's effectiveness. The facility's medication administration policy required staff to administer medications as ordered and in accordance with manufacturer specifications, which was not followed in these instances.