Duplicate Medication Orders and Administration Error
Penalty
Summary
The facility failed to ensure accurate pharmaceutical services for a resident with osteoporosis by allowing duplicate orders for Alendronate 70mg to be entered and administered. The resident had an original physician's order for Alendronate 70mg once weekly on Mondays at 5:00 AM, but a second, duplicate order was later entered for the same medication and dose to be given on Sundays at 7:00 AM. Medication Administration Records showed that both doses were signed as given on multiple consecutive weeks. Staff responsible for resident care were unaware of the duplicate order until it was brought to their attention, and there was an expectation that the system or pharmacy would catch such duplications. Additionally, the facility's medication error report did not thoroughly investigate whether the pharmacy supplied extra tablets or reconcile discrepancies in staff statements regarding the administration of the duplicate medication.