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F0760
D

Medication Error: Incorrect Transcription of PRN Ibuprofen Order

Salem, Oregon Survey Completed on 04-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was administered ibuprofen as prescribed, resulting in a significant medication error. The physician ordered ibuprofen 600 mg by mouth every eight hours as needed (PRN) for chills or fever, but the order was incorrectly transcribed into the Medication Administration Record (MAR) as a scheduled medication to be given three times daily. This error led to the resident receiving nine scheduled doses of ibuprofen over several days, rather than only as needed. The error was not identified by the nurse who entered the order or by the second nurse who reviewed it. The resident, who had a diagnosis of obesity and was elderly, subsequently experienced a significant gastrointestinal event, including a large, dark red liquid bowel movement with clots and rectal bleeding. Laboratory results showed low hemoglobin and hematocrit levels, and the resident was transported to the hospital for evaluation and treatment. Hospital records indicated the presence of a duodenal ulcer and diverticula, with an assessment of acute blood loss anemia and suspected diverticular bleed. The facility's investigation confirmed the medication error and noted that the ibuprofen administration may have worsened the resident's condition.

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