Medication Administration Exceeds Recommended Dose
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including diabetes mellitus, osteoporosis, and muscle weakness, was administered Alendronate Sodium at a dosage exceeding the manufacturer's recommended frequency. The physician's order was incorrectly entered as a daily administration of 70 mg, rather than the intended weekly dose. This error was not identified by the nursing staff, despite medication alerts and packaging instructions indicating the correct weekly dosing schedule. The resident received the medication on three separate days within a week, as documented in the Medication Administration Record. The error was further confirmed through interviews with the resident, who reported receiving the medication more frequently than prescribed, and with the pharmacist, who stated that the pharmacy only supplied four tablets and the packaging clearly indicated weekly dosing. The pharmacist also noted that exceeding the recommended dose could result in adverse effects. Interviews with the DON and a registered nurse revealed that the medication alert indicating the excessive dosage was overlooked, and the order was not clarified with the nurse practitioner or physician until after the error was discovered. The facility's policy required medications to be administered according to physician orders and manufacturer specifications, but this protocol was not followed in this instance.
Plan Of Correction
Determines that the disputed findings are relied upon in a manner adverse to the interests of the provider either by the governmental agencies or third party. Corrective action for residents found to have been affected by this deficiency: - The Physician and/or NP of resident #1 was notified of the medication administration error on May 18, 2025, and the order was clarified. - The Physician was contacted on May 18, 2025, and labs were ordered for resident #1 to rule out any abnormality. Resident's Calcium level was normal, and no other abnormalities were noted. - An order was also obtained for monitoring of Dysphagia. - DON provided 1:1 education with the licensed nurse on May 19, 2025. Identification of others at risk: - DON and/or Designee audited residents with Alendronate 70 mg on May 20, 2025, and no other resident was affected by this practice. Measures that will be put into place to ensure that this deficiency does not recur: - Starting on May 19, 2025, the Director of Nursing initiated in-service with Licensed Nurses on the facility's policy titled "Medication Errors" and "Medication Administration." - Med Pass competency was initiated by the DON/Designee on May 29, 2025, and will be continued by the DSD/Designee on med pass observation to at least one (1) licensed nurse per month for three (3) months. Findings will be reported to the Director of Nursing for follow-up. - Pharmacy Nurse Consultant will perform med pass observation during their monthly scheduled visit. Findings will be reported to the Director of Nursing for follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: - The Director of Nursing will review all new residents with Alendronate orders to ensure orders are transcribed accurately for three (3) months. - The Director of Nursing will provide a summary trend analysis of the facility's compliance on a monthly basis for three months to the QA committee for further evaluation and recommendations until substantial compliance is sustained.