Medication Order Transcription Error Led to Over-Administration
Penalty
Summary
A deficiency occurred when a resident's medication order for Metolazone was incorrectly transcribed in the electronic medical record by a registered nurse. The hospital discharge documentation specified that the resident should receive Metolazone 5 mg by mouth three times a week for 30 days. However, the physician's order entered into the facility's system stated the medication should be given three times a day. As a result, the resident received seven doses of Metolazone over three days, rather than the two doses that were actually ordered. The resident involved had recently been readmitted to the facility with diagnoses including heart failure, pulmonary hypertension, and chronic kidney disease. The error was identified after the resident experienced a fall, was transferred to an acute care hospital, and subsequently passed away. The Director of Nursing Services acknowledged during an interview that the medication order was incorrectly transcribed, leading to the administration of Metolazone at a much higher frequency than prescribed.