Failure to Follow Physician Order for Medication Dosage
Penalty
Fine: $27,165
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A nurse administered a 50 mg dose of Lyrica to Resident #103, despite a current physician order specifying a 25 mg dose to be given once daily for 30 days for the treatment of myalgia. The error occurred during a medication pass when the nurse selected the 50 mg capsule from an outdated medication supply card, rather than the newly prescribed 25 mg supply. The nurse acknowledged the mistake upon review, noting that the resident's order had been changed from 50 mg to 25 mg four days prior, but the previous supply was still available and mistakenly used. The clinical record did not contain any current order for the 50 mg dose, and the incident was confirmed through observation, staff interview, and record review.