Failure to Administer Ordered Extended-Release Medication
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for a resident diagnosed with Parkinson's disease, dementia, lack of coordination, and cognitive communication disease. Upon admission, the resident had physician orders for both regular-release and extended-release (ER) Carbidopa-Levodopa, with the ER formulation to be administered at bedtime. Despite this, staff administered the regular-release medication in place of the ER formulation at night for approximately one month. Medication administration records indicated that the ER medication was documented as given, but in reality, only the regular-release was provided. This error persisted until a family member discovered the discrepancy during a visit, noting increased tremors and ataxia in the resident and observing that the ER tablets were not accessible in the medication cart. Interviews with facility staff, including the DON and the pharmacist, confirmed that the ER medication was not administered as ordered, and the regular-release was substituted instead. The error was also documented in a Medication Error Report. The facility's policy required staff to check medication labels and confirm the medication name and dose with the MAR, but this procedure was not followed, resulting in the resident not receiving the prescribed ER medication for an extended period.