Medication Labeling Discrepancy for Antihypertensive Drug
Penalty
No penalty information released
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Summary
The facility failed to ensure that the pharmacy label for a resident's medication matched the physician's order. Specifically, a resident with hypertensive heart disease and heart failure had a physician's order for Prazosin HCl 1 mg capsules, instructing administration of 2 capsules by mouth twice daily. However, the pharmacy label on the medication card directed staff to give only 1 capsule by mouth twice daily. During medication administration, an LPN prepared and administered the medication according to the label, not the updated physician's order. Upon review, the LPN confirmed the discrepancy between the label and the order, and the Director of Nursing acknowledged that the pharmacy label should match the physician's order.