Medication Transcription Error Leads to Unnecessary Drug Administration
Penalty
Summary
A deficiency occurred when a resident was admitted with a diagnosis of benign prostatic hyperplasia (BPH) and a hospital discharge summary that prescribed Finasteride 5 mg once daily. Upon admission, the facility's physician order was incorrectly transcribed to administer Finasteride 5 mg twice daily, and this error persisted from 10/10/25 through 10/27/25. There was no documentation of a verbal order or any physician notification authorizing this change from the hospital's discharge instructions. Multiple staff interviews confirmed the error in transcription. The nurse responsible for entering the medication orders acknowledged the mistake after reviewing the hospital discharge summary and facility orders, stating she did not recall notifying the physician or nurse practitioner about the discrepancy. The Unit Managers described a cross-check process for admission medication orders, but could not recall the specific admission or confirm that the process was completed for this resident. The Consultant Pharmacist noted that the pharmacy had both the hospital and facility orders, and the medication card matched the hospital's order, but staff were instructed to follow the facility's order, which was incorrect. The Director of Nursing (DON) and Administrator both described a multi-level checks and balances system intended to ensure accuracy of admission medication orders, including an admission Audit Checklist. However, the DON could not provide the checklist for this resident, and acknowledged that the cross-checks likely were not completed. The Medical Director was unaware of the transcription error and stated he would expect nursing staff and the Consultant Pharmacist to verify admission medication orders for accuracy.