Failure to Accurately Transcribe and Administer Medication Orders
Penalty
Summary
The facility failed to ensure that medication orders were accurately transcribed and administered as prescribed for one resident. A physician's order directed that the resident receive Seroquel 50 mg, one tablet twice daily and two tablets at bedtime. However, the order was incorrectly transcribed as Seroquel 25 mg, with instructions to give one tablet twice daily and two tablets at bedtime. This error was reflected in both the Order Summary Report and the Medication Administration Record (MAR), and the resident received the incorrect dosage over a period of time. The error was not identified until it was brought to the attention of the Assistant Director of Nursing (ADON), who acknowledged the mistake and indicated that more frequent audits or reviews might be necessary to prevent such errors. The resident involved had a history of dementia, major depressive disorder, and unspecified mood affective disorder, with moderate cognitive impairment as indicated by a BIMS score of 10. The care plan specifically noted the use of antipsychotic medication and the need to administer medications as ordered. Interviews with facility staff, including the LVN who entered the order and the DON, confirmed that the order was not transcribed correctly and that staff are expected to enter medication orders accurately. The facility's policy required medications to be administered as prescribed, but this was not followed in this instance.