Medication Labeling Discrepancy for Scheduled Tramadol Administration
Penalty
Summary
A deficiency occurred when a resident with intact cognition and multiple medical diagnoses, including a medically complex condition, was observed receiving medication from an LPN. During the medication pass, the LPN retrieved Tramadol HCl 50 mg from the locked medication cart and stated it was administered every eight hours on a routine basis. However, the medication label indicated it was to be given every eight hours as needed, not as a scheduled dose. Review of the electronic medical record and printed orders confirmed the medication was ordered to be given three times daily, not on an as-needed basis. The LPN acknowledged the discrepancy between the medication label and the physician's order, stating that prescription labels should accurately reflect provider orders. The DON confirmed that medication labels are required to match current orders and that staff are expected to verify and request corrections if discrepancies are found. Facility policy directs staff to check medication labels three times to ensure accuracy before administration. Despite these policies, the medication label did not reflect the current physician-ordered administration instructions, creating a risk for administration error.