Duplicate Medication Orders Result in Administration Errors
Penalty
Summary
The facility failed to ensure proper pharmaceutical services and medication administration systems, resulting in a resident receiving duplicate doses of Trelegy Ellipta, an inhaled medication intended for once-daily use. Staff entered two separate orders for the same medication for the same resident, one at 7:00 A.M. and another at 9:00 A.M., and subsequently administered both doses on multiple days as documented in the Medication Administration Record (MAR). The facility's policy required staff to review the MAR, administer medications as ordered, and correct any discrepancies, but these procedures were not followed. The resident involved had significant medical conditions, including stage 4 kidney disease, general anxiety disorder, major depression, hypertension, blindness in one eye, and impaired thought processes related to metabolic encephalopathy. The care plan specified that staff should administer medications as ordered and monitor for side effects and effectiveness. Despite this, the MAR contained duplicate orders for Trelegy Ellipta, and staff administered the medication twice daily on several occasions, contrary to the physician's order for once-daily administration. Interviews with staff revealed that both LPNs and Certified Medication Technicians were aware of duplicate orders appearing on MARs but did not consistently take action to resolve the issue. Some staff attempted to discontinue extra orders when errors were found, while others were unsure why duplicate orders existed. The Director of Nursing confirmed that only one dose per day should have been administered and that staff should have recognized and reported the duplicate order. The administrator stated that nursing should verify that the MAR matches the prescription before administering medication.