Medication Transcription and Administration Errors
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not correctly transcribing physician orders and not ensuring the correct medications and dosages were administered to residents. One resident with multiple diagnoses, including cerebral infarction and dementia, was given incorrect medications such as cetirizine, gabapentin, quetiapine, and memantine, which was discovered by another RN as the nurse was leaving the room. Another resident with liver cell carcinoma and other chronic conditions received an antibiotic for 12 days instead of the prescribed 5 days because the medication stop date was not entered by the nurse. A third resident with a history of chronic bowel disease and repeated falls was prescribed Budesonide 9mg daily, but only received 3mg due to a pharmacy dispensing error that was not caught by staff. Additionally, a resident with urinary tract infection and other chronic illnesses was given a prednisone taper beyond the intended stop date because the order was not entered correctly, resulting in the medication being continued until the error was discovered. These incidents were identified through interviews and record reviews, and all occurred within a three-month period.