Failure to Accurately Transcribe and Administer Chemotherapy Medication Order
Penalty
Summary
The facility failed to provide resident-centered care by not accurately transcribing a physician's order for Lenalidomide, a medication prescribed for a resident with multiple myeloma and bone cancer. The resident, who had moderate cognitive impairment and required significant assistance with daily activities, was admitted with discharge instructions from a general acute care hospital to receive Lenalidomide 20 mg by mouth once daily for the first 21 days of each 28-day cycle. However, the medication order was incorrectly transcribed as Lenalidomide 20 mg every 21 days instead of daily for 21 days on and seven days off. As a result of this transcription error, the resident received the medication only once during the specified period, with the medication administration record showing it was not given on the other days. The error was discovered after the resident's family questioned the remaining medication supply. The facility's policy required accurate recording of medication orders, including type, route, dosage, frequency, and strength, but this was not followed, and the error was not identified or corrected by the RN supervisor responsible for verifying admission orders.