Failure to Ensure Consistent Medication Orders and Packaging
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) identified a discrepancy between the physician's order and the instructions on the medication blister pack for a resident prescribed Carbidopa-Levodopa for Parkinson's disease. The physician's order and the electronic Medication Administration Record (eMAR) both specified to administer one 50-200 mg extended-release tablet by mouth three times daily. However, the blister pack available in the medication cart contained 25-100 mg tablets and was labeled to administer two tablets by mouth three times daily, which would match the total prescribed dose but differed in tablet strength and instructions. During medication administration, the LPN noticed the inconsistency and flagged the medication pack with a sticker indicating a direction change, while also confirming that only one 25-100 mg tablet was administered to the resident at that time. The Director of Nursing (DON) reviewed the orders, eMAR, and blister pack, confirming the mismatch between the physician's order and the medication packaging. There was no documentation in the eMAR to indicate the irregularity or conflict between the orders and the medication available for administration.