Failure to Accurately Transcribe and Administer Anti-Seizure Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate transcription and administration of medications for a resident admitted with a seizure disorder, cerebral infarction, and hypertension. Upon admission from the hospital, the resident's discharge orders specified Divalproex Sodium ER 1000 mg twice daily, but the facility's physician order was transcribed as 250 mg every 12 hours. The resident subsequently received only 250 mg twice daily throughout her stay, as documented in the Medication Administration Records (MARs). There was no documentation or evidence that the physician or nurse practitioner reviewed or corrected the medication order to match the hospital discharge instructions. Interviews with facility staff revealed inconsistent procedures for verifying and documenting new admission medication orders. The LVN responsible for transcription stated there was no protocol for documenting verification with the physician or nurse practitioner, and the DON confirmed there was no set process for order verification. The nurse practitioner reported she instructed the nurse to continue all hospital medications but did not review the orders herself. The discrepancy in the Divalproex Sodium ER dosage was identified by the resident's family after discharge, and there was no indication in the record that the error was recognized or addressed by facility staff during the resident's stay.