Failure to Clarify and Transcribe Accurate Medication Orders for Parkinson's Treatment
Penalty
Summary
The facility failed to accurately transcribe and clarify medication orders for one resident with Parkinson's Disease following a neurology clinic visit. The resident, who had a history of progressive neurological condition, diabetes, anemia, and other comorbidities, required precise dosing of carbidopa-levodopa (Sinemet) and its extended-release formulation. After the clinic visit, the documentation from the neurologist contained conflicting information regarding the medication regimen, with discrepancies between the narrative, medication lists, and the plan section of the summary. Despite these inconsistencies, staff did not seek timely clarification of the orders. As a result, the resident was administered an incorrect dose of medication for 12 days. The facility's records showed that the resident received only the regular formulation and not the extended-release tablets as previously prescribed. The MAR/TAR indicated frequent use of the PRN dose, and nursing notes documented the resident's increased stiffness and inadequate symptom control during this period. The DON eventually contacted the neurologist after observing the resident's condition and the high use of PRN medication, but this was not done immediately after the conflicting orders were received. The facility's policy required clarification of unclear or incomplete orders, but staff relied on the section of the summary that stated there were no changes to the medications, overlooking the plan section that detailed the intended regimen. The administrator acknowledged the contradictory information in the neurologist's summary and confirmed that staff did not pay attention to all relevant sections. This failure to clarify and accurately transcribe the medication orders led to the resident receiving an incorrect medication regimen for an extended period.