Failure to Provide Correct Dosage of PRN Pain Medication Due to Pharmacy Communication Breakdown
Penalty
Summary
A deficiency occurred when a resident with multiple chronic conditions, including congestive heart failure and diabetes with neuropathy, was readmitted from the hospital with a new physician order for as-needed Tramadol HCL 50 mg for pain. Despite the new order being entered into the electronic medical record, the prescription for the new dosage was not sent to the pharmacy, resulting in the pharmacy not dispensing the correct medication. As a result, the facility continued to have the discontinued 75 mg dose available in the medication cart, and the resident received the incorrect dosage on multiple occasions over two months. Multiple nursing staff, including agency nurses, administered the discontinued 75 mg dose instead of the newly ordered 50 mg dose, as documented on the controlled medication declining sheet and confirmed in staff interviews. Several nurses were unaware of the need to send a new prescription to the pharmacy when a narcotic dosage changed, and some had not received education on returning discontinued narcotics. The medication cart was observed to contain only the 75 mg blister packs, and staff relied on what was available in the cart, assuming it matched the current order. Interviews with the pharmacist, medical director, and facility leadership confirmed that the pharmacy had not received a prescription for the new dose and that the expectation was for discontinued medications to be returned and new prescriptions to be sent for dose changes. The failure to communicate the new order to the pharmacy and to remove the discontinued medication from the cart led to the resident receiving the wrong dose of pain medication on several occasions.