Failure to Administer Prescribed Clonidine Patch Due to Order and Communication Errors
Penalty
Summary
The facility failed to implement the plan of care for one resident regarding medication administration. The resident, who had a diagnosis including bipolar disorder, reported not receiving his prescribed Clonidine patch for several weeks. Review of the medical record confirmed that the Clonidine patch was not administered on two occasions, with documentation indicating the medication was not available and had been reordered. The hospital discharge orders specified a Clonidine patch, but the order entered into the facility's electronic medical record incorrectly listed a tablet to be given transdermally. This discrepancy led to the pharmacy delivering the incorrect form of the medication, and the resident did not receive the intended treatment as ordered. Interviews with staff revealed that nursing was aware of the issue, as a pill was delivered instead of a patch, but the problem was not escalated promptly. The DON acknowledged that the receiving nurse should have verified the order and contacted the pharmacy upon noticing the error. Facility policies required nursing staff to communicate medication order discrepancies to the pharmacy and DON, and to ensure medications are administered as prescribed. However, these procedures were not followed, resulting in the resident missing prescribed doses of the Clonidine patch.