Resident Received Incorrect Dose of Hydromorphone
Penalty
Summary
A resident with a history of surgical amputation and end stage renal disease was admitted to the facility and had a physician's order for hydromorphone oral tablets. Initially, the order was for four milligrams (mg) every six hours for pain, but it was later changed to 0.5 tablet (2 mg) every six hours. Despite this change, review of the controlled drug record revealed that the resident received a whole 4 mg tablet on 14 occasions instead of the prescribed 2 mg dose. This error was confirmed through interviews with facility staff, including a registered pharmacist and an LPN, both of whom acknowledged that the medication was administered at the incorrect dose and that the physician's order was not followed. The facility's policy required regular audits of controlled substance inventory records, but the error was not detected until after multiple incorrect doses had been administered. The pharmacist noted that the interface between the pharmacy and the facility did not communicate narcotic orders effectively, and that a hard copy of the order was required. The LPN involved confirmed that she had given a whole pill instead of half, and the DON agreed that the medication was not administered as ordered. The failure to follow the physician's order resulted in significant medication errors for the resident.