Failure to Timely Notify Physician and Family of Medication Error and Change in Condition
Penalty
Summary
The facility failed to promptly notify the physician and resident representative of a significant change in condition for a resident diagnosed with Parkinson's disease and dementia. The resident was admitted with intact cognition and had a physician order for ropinrole 0.5 mg three times daily. However, the medication order was incorrectly entered into the Medication Administration Record (MAR) as 5 mg four times daily, resulting in the resident receiving a much higher dosage than prescribed over several administrations. During the period the incorrect dosage was administered, the resident experienced symptoms including hypertension, headache, hallucinations, increased anxiety, and dizziness. Despite these symptoms and the discovery of the medication error, there was no evidence that the physician or the resident's family were notified of the error or the resident's change in condition until the following day. The facility's policy required immediate notification of the attending physician and resident advocate in the event of a significant change in medical condition, which was not followed in this instance.