F0658

D

Unreported Oxybutynin Dosing Error Identified but Not Acted Upon

Hagerstown, Maryland Survey Completed on 01-29-2026

Penalty

Fine: $21,665

Summary

Facility staff failed to ensure that services met professional standards of quality when a medication error involving oxybutynin was not reported or acted upon after it was identified. Medical record review of one resident’s MAR showed that the resident had been ordered and receiving a double dose of oxybutynin chloride ER, 20 mg instead of the intended 10 mg, from 1/9/26 until the date of review on 1/21/26. Oxybutynin is identified in the report as an anticholinergic medication used to treat overactive bladder, with overdose symptoms that may include central nervous system overactivity, rapid heartbeat, high blood pressure, anxiety, headaches, fever, cardiac arrhythmia, vomiting, respiratory failure, paralysis, and coma.

Further review of the resident’s medical record showed that a nephrology NP consultant completed a consultation on 1/13/26 and documented that the resident was receiving a duplicate dose of oxybutynin. In that consultation, the NP did not recommend continuation of oxybutynin, unlike two other urinary medications, and recommended monitoring for lower urinary tract symptoms (LUTS). However, the NP did not report the medication error to facility staff, did not follow up on the issue, and only uploaded the consult into the EHR on 1/15/26, two days after completion. In an interview, the DON stated that when she later questioned the NP about why the error had not been brought to anyone’s attention, the NP said she did not want to get anyone in trouble. These actions and inactions resulted in the medication error going unreported and unaddressed for an extended period.