Failure to Follow Physician's Orders for Medication Dose Reduction
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident who was scheduled to undergo a gradual dose reduction (GDR) of Lyrica (Pregabalin). According to the nursing note, the provider ordered a tapering of Lyrica from 200 mg three times daily, reducing the dose by 100 mg per day to be completed over 25 days. The medication administration record (MAR) indicated that a 100 mg dose was to be given at noon for five days starting on 4/4/25. However, the narcotic administration record showed that the resident continued to receive the previous 200 mg dose at noon from 4/4/25 through 4/6/25, rather than the reduced 100 mg dose as ordered. A review of the records and an interview with a registered nurse confirmed that the resident did not receive the correct dose of Lyrica during this period. The error was discovered when the nurse attempted to administer the noon dose and realized that the 100 mg capsules were not available in-house, leading to the continued administration of the higher 200 mg dose. This discrepancy between the physician's order and the medication actually administered constituted a failure to meet professional standards of quality in medication administration.