Incorrect Medication Labeling and Dosing Instructions Identified
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled accurately and in accordance with the physician's order for one resident. During a medication pass, a nurse prepared to administer metoprolol to a resident as ordered in the electronic Medication Administration Record (eMAR) for a dose of 37.5 mg twice daily. The nurse obtained two medication cards from the pharmacy, one containing 25 mg tablets and another containing 12.5 mg tablets, and combined them to reach the prescribed dose. However, the labels on both medication cards contained incorrect dosing instructions, stating to administer a total of 75 mg twice daily, which did not match the physician's order. The nurse acknowledged that the labeling on the medication cards was incorrect and had not previously noticed the discrepancy, despite routinely administering the medication. The Director of Nursing confirmed that the error in the pharmacy labeling could have resulted in the resident receiving twice the ordered dose if the instructions had been followed. The facility's policy required verification of medication labels and administration in accordance with prescriber orders, but this process failed to identify the incorrect pharmacy directions prior to the surveyor's observation.