Incorrect Medication Delivered by Pharmacy
Penalty
Summary
The facility failed to ensure that the pharmacy provided an accurate, physician-prescribed medication for a resident. According to the medical record, the resident was admitted with diagnoses including Alzheimer's Disease, Dementia, Osteoarthritis, and Glaucoma, and had a current physician order for Vitamin D3 oral capsule 1.25 mg to be administered once weekly. During medication administration, a registered nurse retrieved a medication card containing Vitamin D2 instead of the prescribed Vitamin D3. The interim Director of Nursing confirmed that the medication card, dated over a month prior, contained Vitamin D2 and that the pharmacy had not delivered the correct medication as ordered. The pharmacy consultant also confirmed that Vitamin D2 was delivered and was unable to explain why the incorrect medication was sent.