Medication Transcription Error on Admission
Penalty
Summary
A deficiency occurred when a resident was admitted with diagnoses including depression and a severe left leg fracture. Upon admission, the community referral form did not include a physician order for the antipsychotic medication Seroquel 100 mg, but did include an order for the antidepressant sertraline 100 mg daily. However, a physician order for Seroquel 100 mg was incorrectly entered upon admission, and the medication administration record showed that Seroquel 100 mg was administered to the resident the morning after admission. The error was traced to a transcription mistake during the admission process, resulting in the resident receiving Seroquel 100 mg instead of the intended sertraline 100 mg. The incident was identified when a registered nurse reviewed the resident's medications the day after admission and discovered the error, by which time the incorrect medication had already been administered. The facility's policy required medications to be administered as ordered by the physician, but this was not followed due to the transcription error.