Failure to Administer Correct Dosage of Ordered Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for a resident with multiple medical conditions, including heart failure, ankylosing spondylitis, and spinal stenosis. The resident had a physician's order for naproxen 250 mg to be administered twice daily, but instead, staff consistently administered an over-the-counter naproxen 220 mg tablet. This discrepancy was not identified by the medication aide or the charge nurse until it was observed by a surveyor during a medication pass. The medication administration record (MAR) and active physician orders both reflected the 250 mg dosage, but only 220 mg tablets were available and given. The medication aide admitted to administering the 220 mg tablets since the order was written, without noticing the dosage mismatch. The charge nurse was also unaware of the discrepancy until notified during the survey. Both staff members acknowledged that medication administration should involve verifying the correct dosage against the physician's order and the medication label. The facility's policy required staff to check the medication label three times to ensure the right resident, medication, dosage, time, and route before administration. Despite this policy and documented competency in medication administration, the error persisted for several months. The Director of Nursing and the Administrator were not aware of the mismatch until the survey, and both confirmed that staff are expected to verify medication orders and dosages prior to administration.