Medication Order Error Leads to Unnecessary Doses Administered
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and diagnoses of unspecified dementia and generalized anxiety disorder received four additional doses of hydroxyzine 25 mg that were not ordered by the treating physician. The resident's medication regimen was reviewed by the 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, an agency LPN entered a new order for hydroxyzine 25 mg TID, contrary to the physician's instructions. The LPN stated they believed the physician intended the resident to continue on the TID dose, despite confirmation from the physician for the BID order. This incorrect order resulted in the resident receiving four extra doses of hydroxyzine over several days. The error was discovered when another nurse reviewed the resident's orders and found the discrepancy. The nurse confirmed with the physician that the correct order was for hydroxyzine 25 mg BID, not TID. The DON and administrator confirmed that the LPN had changed the order without proper authorization, leading to the administration of unnecessary medication doses to the resident.