Failure to Administer Correct Medication Dose and Notify Providers of Drug Interaction Alerts
Penalty
Summary
Facility staff failed to order and administer the correct dose of quetiapine fumarate for a resident, resulting in the resident receiving double the prescribed amount on two occasions. The resident, who had multiple complex medical conditions including COPD, asthma, chronic respiratory failure, major depressive disorder, and moderate cognitive impairment, was admitted with specific medication orders from the hospital. However, discrepancies occurred during the transcription of these orders, leading to the administration of 25 mg of quetiapine instead of the intended 12.5 mg. The error was not identified until after the incorrect doses had been given. Additionally, when entering the resident's medications into the pharmacy system, multiple drug-to-drug interaction alerts were triggered, some of which were classified as severe. These included potential additive QT interval prolongation and increased risk of serotonin syndrome due to the combination of several psychotropic and other medications. Despite these alerts, there was no documentation that the physician was notified or that the pharmacy was consulted regarding the warnings. Interviews with facility staff, including an LPN and the DON, confirmed that the expectation was for nurses to notify physicians and consult with the pharmacy when such alerts occur. However, the staff did not follow these protocols, and the prescribing providers were not made aware of the medication errors or the significant drug interaction warnings. The deficiency was brought to the attention of the facility administration during the survey process.