Failure to Administer Chemotherapy Medication as Ordered Due to Transcription Error
Penalty
Summary
A deficiency occurred when a resident with multiple myeloma and bone cancer did not receive their prescribed medication, Lenalidomide, as ordered. The resident was admitted with instructions from the discharging hospital to receive Lenalidomide 20 mg orally once daily for the first 21 days of each 28-day cycle. However, the medication order was incorrectly transcribed by a desk nurse as 'one capsule by mouth one time a day every 21 days,' rather than daily for 21 days. As a result, the resident received only one dose of Lenalidomide during the period from 5/16/2025 to 5/31/2025, with the medication administered only on 5/22/2025 and not on the other days as required. The error was not identified by the facility's medication administration checks or by the RN supervisor responsible for verifying admission orders. The mistake was discovered when the resident's daughter questioned the number of capsules remaining in the medication bottle. The facility's policies required medications to be administered as prescribed and for orders to be accurately recorded, specifying type, route, dosage, frequency, and strength, but these procedures were not followed in this instance.