Incorrect Medication Order Leads to Unnecessary Psychotropic Drug Administration
Penalty
Summary
A deficiency occurred when a resident with diagnoses of unspecified dementia and generalized anxiety disorder received unnecessary doses of a psychotropic medication due to incorrect medication orders. The resident's medication regimen was under review, and the consulting pharmacist recommended a gradual dose reduction (GDR) of hydroxyzine 25 mg, which was initially prescribed three times daily (TID) for anxiety. The physician agreed with the recommendation and ordered the dose to be reduced to twice daily (BID). The Director of Nursing (DON) entered the new BID order into the resident's chart as directed by the physician. However, an agency LPN subsequently changed the order back to TID without proper verification, despite the physician's confirmation of the BID order. The LPN stated that they believed the physician intended for the medication to remain at TID and entered the order accordingly, even though the DON and the physician had already confirmed the reduction to BID. This unauthorized change resulted in the resident receiving four additional doses of hydroxyzine between the dates the error occurred and when it was discovered. The error was identified when another nurse reviewed the resident's orders and noticed the discrepancy. The nurse confirmed with the physician that the correct order was for BID dosing, not TID. The facility's records and interviews confirmed that the LPN had altered the medication order without a physician's directive, leading to the administration of unnecessary medication doses to the resident.