Significant Medication Error Due to Incorrect PRN Methocarbamol Administration
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from significant medication errors. Specifically, the resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, had physician orders for Methocarbamol 500 mg to be administered as needed (PRN) once daily for muscle spasm, and a separate order for Methocarbamol 500 mg to be given twice daily for pain/spasm. Review of the Medication Administration Records (MAR) revealed that the PRN Methocarbamol was administered more frequently than ordered, with doses given twice daily on multiple dates, rather than the prescribed once daily. Interviews with the Unit Manager and Director of Nursing confirmed that the PRN Methocarbamol was administered outside the parameters of the physician's orders, resulting in a significant medication error. The error was identified through record review and staff interviews, which indicated that the medication was given too close to the scheduled doses, contrary to the physician's instructions.