Chemotherapy Medication Administered in Excess of Prescribed Duration
Penalty
Summary
The facility failed to ensure that chemotherapy medications were administered as ordered for a resident with a diagnosis of Glioblastoma. The resident was supposed to receive temozolomide, a chemotherapy drug, for five days as part of a 28-day maintenance cycle, in accordance with standard dosing schedules and the prescriber's intent. However, due to a lack of clear documentation and order verification, the medication was administered daily for 23 consecutive days, far exceeding the prescribed duration. The error originated when a nurse transcribed the temozolomide order into the resident's clinical record without confirming the exact duration of administration, despite having a conversation with the neuro-oncology clinic. The nurse could not recall the specific instructions regarding the number of days the medication was to be given and relied on a paper order that was never located during the subsequent investigation. The Director of Nursing did not verify the entry or the existence of a valid paper order, and the medication was administered according to the incorrect transcription. The facility's policy required clarification of ambiguous orders and documentation of such clarifications, but this process was not followed. As a result of the prolonged administration of temozolomide, the resident developed severe complications, including thrombocytopenia, pancytopenia, and neutropenia, which necessitated multiple blood transfusions, emergency department visits, and hospitalizations. Interviews with facility staff and the resident's medical providers confirmed that the medication was given for a much longer period than intended, directly leading to these adverse outcomes.