Failure to Discontinue and Dose Depakote Correctly
Penalty
Summary
A deficiency occurred when a resident with major depressive disorder and moderately impaired cognition continued to receive the anticonvulsant medication Depakote beyond the prescribed period and at the incorrect dose. The Psychiatrist had ordered a gradual dose reduction and discontinuation of Depakote, specifying a 14-day course of 125 mg twice daily, after which the medication was to be stopped due to the resident's concurrent use of Keppra. However, the order entered into the electronic medical record by the Director of Nursing did not include the 14-day stop date, resulting in the order remaining active past the intended discontinuation date. During medication administration, nursing staff continued to give Depakote to the resident after the 14-day period, and on at least one occasion, administered a 250 mg tablet instead of the prescribed 125 mg dose. The 250 mg tablets, which should have been removed from the medication cart when the new order was written, remained accessible and were used in error. Nursing staff were unaware that the Depakote should have been discontinued and that the correct dose was 125 mg, not 250 mg. The resident received 25 additional tablets of Depakote and the wrong dose over this period. Interviews with the Psychiatrist, Nurse Practitioner, and pharmacy representative confirmed that the medication was not discontinued as ordered and that the higher dose was administered. The resident did not exhibit any significant adverse outcomes or increased sedation as a result of the error, and no Depakote levels were checked since the medication was prescribed for mood and not for seizure control. The error was identified during a surveyor's observation and subsequent review of records and staff interviews.