Incorrect Medication Dosage Administered Due to Order Entry and Pharmacy Review Errors
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's disease, history of stroke, and weakness was not provided with the correct dosage of Rytary, a medication used to treat Parkinson's symptoms. The resident's physician orders for Rytary changed multiple times, with one order indicating four capsules four times daily, but due to an error by the admitting nurse, the order was incorrectly entered as one capsule four times daily. This incorrect dosage was then perpetuated when the pharmacy, upon review, referenced an older resident profile and confirmed the lower dose, leading to the resident receiving less medication than prescribed. The issue was identified after a weekend nurse questioned the medication dosage, prompting further review. Interviews with the DON and review of facility communications revealed that both nursing and pharmacy staff contributed to the error by relying on outdated information and not verifying the most current physician order. The facility's policy required an Immediate Medication Regimen Review (IMRR) by a licensed pharmacist upon request, but the review did not catch the discrepancy, resulting in the resident not receiving the intended medication dose for a period of time.