Failure to Identify and Report Duplicate Medication Orders
Penalty
Summary
The facility failed to ensure that a licensed pharmacist accurately identified and reported drug regimen irregularities for a resident with multiple medication orders. Specifically, a male resident with quadriplegia and generalized anxiety disorder had two active orders for Buspirone 5 mg: one to be administered twice daily and another three times daily, both without end dates. Medication administration records showed that both orders were being followed concurrently, resulting in duplicate administration of the same medication. Despite the presence of duplicate orders, the consultant pharmacist's monthly drug regimen review did not identify or report this irregularity. The pharmacist stated that only the three times daily order was documented in her notes and denied awareness of the twice daily order, even though both were present in the facility's electronic medical record and being administered. Interviews with nursing staff and medication aides confirmed the existence of duplicate orders and acknowledged that the previous order should have been discontinued when the new one was entered. The facility's policies required new physician orders to be reviewed for accuracy during daily clinical meetings, but the duplicate orders for Buspirone were not identified or addressed until after the issue was brought to attention. The resident was alert and showed no signs of distress at the time of observation, and staff interviews indicated a lack of ongoing training regarding medication management for some personnel. The deficiency was identified through record review and staff interviews, highlighting a lapse in the facility's medication review and reporting processes.