Failure to Ensure Correct Dose of Antidepressant Administered
Penalty
Summary
Facility staff failed to ensure that a resident received the correct dose of Trazodone, an antidepressant medication, as ordered by the physician. The resident, who had multiple diagnoses including Major Depressive Disorder, Dementia, and Metabolic Encephalopathy, had a physician's order for Trazodone 50 mg at bedtime, which was later changed to 0.5 tablet (25 mg) and then back to 50 mg. During a medication cart observation, it was found that only 25 mg tablets (half-tablets) were available, and there was no clear documentation or assurance that the correct 50 mg dose was being administered as ordered for five consecutive days. Review of the Medication Administration Record (MAR) indicated that staff documented administration of the 50 mg dose, but the Assistant Director of Nursing could not confirm whether two 25 mg tablets were given to make up the correct dose. The resident experienced an episode of lethargy and was sent to the emergency room for altered mental status, though no new findings were reported and the resident returned to the facility. The facility's policy required medications to be administered according to prescriber's orders and for staff to verify the right dose, but this was not ensured in this case.