Medication Administration Error Due to Pharmacy Packaging
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate receiving, dispensing, and administration of medication for a resident. According to facility policy, medications are to be administered as prescribed and in accordance with manufacturer specifications and good nursing practices. However, a medication card delivered from the pharmacy was labeled as rosuvastatin calcium but actually contained coumadin tablets. This error resulted in the resident, who was moderately cognitively impaired and had a diagnosis of heart failure, receiving coumadin instead of the prescribed rosuvastatin calcium for several days before the mistake was identified. Clinical documentation showed that the error was discovered when staff became aware that the medication card contained the wrong medication. The resident subsequently underwent lab work, which revealed an elevated INR, and the physician was notified. The incident was confirmed through interviews and review of records, which indicated that the pharmacy had packaged the medication incorrectly, leading to the administration error.