Failure to Identify and Correct Harmful Medication Dosing Error
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competencies in medication administration, resulting in a resident receiving harmful doses of thyroid medication. Upon admission, the resident had multiple diagnoses, including cirrhosis, diabetes mellitus, hypertension, hypothyroidism, and Parkinson's disease. The resident was ambulatory and able to care for themselves at the time of admission. However, due to a transcription error, the frequencies for Carbidopa/Levodopa and Levothyroxine were switched, leading to the resident receiving five times the prescribed dose of Levothyroxine for several consecutive days. Nursing staff did not identify the incorrect dosing parameters or recognize the resulting side effects. Progress notes indicated that the resident became confused, febrile, tachycardic, and lethargic, with abnormal vital signs and a need for oxygen. Despite these symptoms and the fact that the medication orders exceeded the usual dosing regimen, staff assumed the orders were correct, particularly because the resident was on hospice care. Interviews with nursing staff revealed that they did not verify the medication orders against the admission paperwork or question the unusual dosing frequency, instead relying on the assumption that the orders had been entered correctly. The facility's policy required nurses to verify medication labels against the medication administration record and to resolve any discrepancies before administering medication. However, this procedure was not followed, and the resident received a total of 2800 mcg of Levothyroxine within a 96-hour period. The resident's condition deteriorated significantly during their stay, and they expired at home the day after discharge from the facility.