Failure to Document and Verify Family-Supplied Medications Leads to Medication Error
Penalty
Summary
The facility failed to properly document and inventory medications brought in by a resident's family following a hospital discharge. Upon admission, the resident, who had a history of kidney transplant, was to receive tacrolimus 0.5 mg capsules, three capsules twice daily, as ordered by the physician. However, there was no documentation regarding the medications provided by the family, including the number of bottles, dosages, or verification that the medication labels matched the physician's orders. Staff did not inventory or record the details of the medications upon receipt, and there was no evidence that the facility's pharmacist was asked to review or oversee the medications supplied by the family. A medication error occurred when the resident was moved to a different hall within the facility. During this transition, the wrong bottle of tacrolimus was placed on the new medication cart. As a result, the resident received three capsules of 1 mg each, totaling 3 mg, instead of the prescribed three capsules of 0.5 mg each, totaling 1.5 mg. Nursing staff involved in the administration of the medication did not verify the label against the physician's order, and there was confusion among the nurses regarding the correct dosage and bottle. The error was discovered after the resident questioned the medication and brought it to the attention of the staff. Interviews with facility staff, including nurses and the DON, revealed that there was no clear process for verifying, documenting, or storing medications brought in by families. The facility's own policies required that medications admitted with residents be checked for proper packaging and labeling, and that the administering nurse verify the medication label three times before administration. These procedures were not followed, leading to the administration of an incorrect dose of tacrolimus to the resident.