Medication Order Entry Errors Result in Missed and Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure that residents received medications as clinically indicated and were free from unnecessary medications for two out of four sampled residents. One resident, admitted with a history of seizures and acute kidney failure, did not receive his prescribed anti-seizure medication, Valproic Acid, because the order was not entered into his medication list upon admission. Instead, the medication order was mistakenly entered for another resident who did not have a clinical indication for Valproic Acid. The second resident, admitted with diagnoses of rhabdomyolysis and muscle weakness, received Valproic Acid in error. This resident was administered a total of nine doses of the medication over several days, despite having no clinical indication for its use. The error was confirmed through review of the medication administration records and interviews with facility staff, including the DON and the admitting RN, who acknowledged the mistake in entering the medication order for the wrong resident. The facility did not have a written policy and procedure for the admission process, including medication orders. The admitting RN stated she did not double-check the medication order against the hospital discharge records or confirm with the physician prior to entering the order. The pharmacist confirmed that pharmacy review of new admission medication orders does not typically include review of hospital discharge records, which is considered the facility's responsibility. As a result, one resident did not receive necessary medication for his condition, while another received unnecessary medication.