Failure to Clarify and Administer Parkinson's Medication Orders
Penalty
Summary
Nursing staff failed to competently administer medication for a resident with multiple complex diagnoses, including Parkinson's Disease, following re-admission to the facility. The resident's hospital discharge orders included both immediate-release and extended-release carbidopa-levodopa, with specific dosing instructions. However, the extended-release medication was ordered as 'as needed' rather than as a routine medication, which was highly unusual and not consistent with the resident's established regimen. The medication administration record showed that the resident had not received any extended-release carbidopa-levodopa since re-admission. Interviews with facility staff, including the pharmacist, nurse practitioner, and nursing leadership, revealed that the medication orders were unclear and should have been clarified upon admission. The nurse practitioner was unaware of the 'as needed' order for the extended-release medication and believed there may have been a transcription error. The neurologist's office confirmed that the resident had been taking both forms of carbidopa-levodopa routinely for 1-2 years and that the facility had not communicated with them regarding the resident's re-admission or medication changes. Facility policies and job descriptions required nursing staff to clarify unclear orders and ensure accurate medication reconciliation at admission. Despite these requirements, the orders were not clarified, and the resident did not receive the prescribed extended-release medication. This failure was acknowledged by multiple staff members, including the RN responsible for auditing the orders, the nurse practitioner, and the director of nursing.