Inaccurate Medication Administration Documentation for Antidepressant
Penalty
Summary
Facility staff inaccurately documented the administration of Trazodone 50 mg to a resident with multiple diagnoses, including major depressive disorder, dementia, and metabolic encephalopathy. The resident's physician order specified Trazodone HCl 50 mg, one tablet by mouth at bedtime for depression. The Medication Administration Record (MAR) indicated that staff documented the administration of the full 50 mg dose on several consecutive days. However, observation of the medication cart revealed that only 25 mg half-tablets of Trazodone were available for the resident, with the blister pack labeled for administration of 0.5 tablet (25 mg) at bedtime. There was no evidence that the resident received the full 50 mg dose as ordered, and staff could not confirm whether two half-tablets were given to equal the prescribed dose. The Assistant Director of Nursing acknowledged the discrepancy and was unable to verify the actual administration of the correct dosage.