Failure to Accurately Transcribe and Administer Routine Medication Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure the accurate receiving and administration of routine medications for a resident with a diagnosis including unspecified polyneuropathy and moderate cognitive impairment. The resident had physician's orders for Lyrica at specific dosages and times, but due to an incorrectly entered order by facility staff, the resident experienced an interruption in their routine medication and an unprescribed dosage reduction. The medication administration record showed missed doses of Lyrica at various times, and progress notes documented that the resident did not receive the medication as ordered, with pharmacy communication issues and delays in medication delivery. The resident reported increased pain in their legs and feet during the period of reduced medication, and staff confirmed that the change in Lyrica dosage was made without physician authorization. Interviews with nursing staff revealed that the original physician order was entered incorrectly into the electronic record, resulting in the resident receiving less medication than prescribed. Facility policy required that all physician orders be implemented and followed as received, but this was not adhered to in this instance.