Medication Order Transcription and Administration Errors
Penalty
Summary
A deficiency occurred when a resident with diagnoses including diabetes and heart failure was administered medications that did not match the physician's orders. The resident, who was cognitively intact according to a recent assessment, was observed receiving 81 mg of enteric coated (EC) aspirin and two sprays of fluticasone propionate nasal spray in each nostril. However, the physician's orders specified aspirin 81 mg in capsule form (which was incorrectly transcribed from the hospital discharge summary that indicated EC tablet) and only one spray of fluticasone propionate in each nostril. The registered nurse administering the medications was unsure why the aspirin order was transcribed as a capsule and acknowledged that the facility did not have aspirin in capsule form. Upon review, it was confirmed that the order was incorrectly transcribed and the medication was not administered as ordered. Additionally, the nurse confirmed that the resident received double the prescribed dose of fluticasone propionate. The Director of Nursing verified these discrepancies and confirmed that the medications were not administered according to the physician's orders.