Incorrect Medication Order Entry Led to Unnecessary Administration of Anti-Anxiety Medication
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and diagnoses of unspecified dementia and generalized anxiety disorder received an anti-anxiety medication, hydroxyzine, in a manner inconsistent with physician orders. The resident's medication regimen was reviewed by a consultant pharmacist, who recommended a gradual dose reduction (GDR) of hydroxyzine from three times daily (TID) to twice daily (BID). The primary care physician agreed and ordered the reduction, which was entered into the resident's chart by the Director of Nursing (DON). Despite the physician's order to reduce the hydroxyzine dose to BID, an agency LPN subsequently entered a new order for hydroxyzine 25 mg TID, contrary to the physician's instructions. This change was made after the LPN claimed to have clarified with the physician, but in reality, the physician had confirmed the BID order. The LPN admitted to changing the order to TID without proper verification, influenced by requests from medication aides, and not based on a new physician directive. As a result of the incorrect order entry, the resident received four additional doses of hydroxyzine 25 mg between the dates the error occurred and when it was identified. The error was discovered by an RN, who noticed the discrepancy and confirmed with the physician that the correct order was for BID dosing. The facility's records and interviews confirmed that the LPN's unauthorized change led to the administration of unnecessary medication doses.