Medication Administration Error Due to Dosage Confusion
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a resident with end stage kidney disease, diabetes, and pulmonary hypertension was not given the correct dosage of Uptravi (selexipag). The resident was admitted with a physician's order for Uptravi 200 mcg tablets, four tablets by mouth twice daily (totaling 800 mcg per dose). However, the medication bottle provided by the family was labeled for 800 mcg tablets, with instructions to give one tablet twice daily. Nursing staff administered the medication based on the Medication Administration Record (MAR), which directed four tablets per dose, without consistently verifying the actual tablet strength on the medication bottle label. This led to confusion and inconsistent administration, with some staff giving one tablet and others giving four, depending on whether they followed the MAR or the bottle label. Interviews revealed that staff did not always read the medication bottle label and relied solely on the MAR, resulting in the medication supply depleting faster than expected. The family raised concerns after noticing the medication was running out quickly and questioned the staff's ability to read the label. The Director of Nursing became aware of the issue when a refill was requested earlier than anticipated and began investigating the discrepancy. Facility policy required that medications brought in by family be properly labeled and verified by a physician or pharmacist prior to use, but there was no documentation that this verification had occurred for this medication.