Significant Medication Error: Double Dosing of Donepezil
Penalty
Summary
A deficiency occurred when a resident was administered Donepezil HCL Oral Tablet 10 mg twice daily for approximately two weeks, despite the physician's order specifying a dose of 10 mg once daily. This error was identified through observation, interview, and record review, which revealed that the medication was given at double the prescribed frequency from 11/14/2025 to 11/26/2025. The error was discovered after the resident's family reported insurance would not cover more than one tablet per day, prompting a review of the medication orders and administration records. The resident involved had a history of advanced dementia, metabolic encephalopathy, and muscle weakness, and was at risk for falls and nutritional problems. During the period of the medication error, the resident experienced a worsening mental status, as documented in a hospital report, which noted that the increase in Donepezil dosage coincided with the decline in mentation. The resident was alert only to person at the time of hospital evaluation, and no other sources of infection or acute illness were identified as contributing factors. Facility records showed that the medication order for Donepezil was incorrectly entered into the electronic medical record (EMR) as 10 mg twice daily, despite a dose warning indicating that this frequency exceeded the usual recommendation. The error persisted until it was recognized and the resident was subsequently sent to the hospital for evaluation. Interviews with staff confirmed that the error was not identified until after the family inquiry, and that the physician and pharmacy were notified only after the error was discovered.