Incorrect Transcription and Administration of B12 Injection
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of Vitamin B Deficient Anemia due to Intrinsic Factor Deficiency did not have the correct order for her B12 injection transcribed in the facility records. The resident, who was fully alert and able to make her own care decisions, had been receiving daily injections of methylcobalamin (Vitamin B12) 20 mg/ml, 1 ml daily (20,000 mcg), which she stored in her room and obtained herself because she found the facility pharmacy too expensive. The nurses had been administering this medication daily for several months using the medication the resident provided. However, the physician's order on file and the Medication Administration Records (MAR) documented a different medication and dosage: cyanocobalamin (vitamin B-12) 1,000 mcg daily. This discrepancy between the medication administered and the physician's order was not identified or corrected until the survey, and no explanation was provided for the incorrect transcription of the medication order. The issue was confirmed through observation, record review, and interviews with facility staff.