F0757

D

Failure to Prevent Duplicate Oxybutynin Therapy

Hagerstown, Maryland Survey Completed on 01-29-2026

Penalty

Fine: $21,665

Summary

Facility staff failed to ensure a resident’s drug regimen was free from unnecessary drugs by administering duplicate oxybutynin therapy over a sustained period. Medical record review showed that the resident was admitted after a fall with rib fractures for monitoring of routine healing and also had diagnoses of overactive bladder and benign prostatic hyperplasia. Review of the physician orders and MAR revealed two concurrent orders: Oxybutynin Chloride ER 5 mg (2 tablets) every morning for bladder spasms and Oxybutynin Chloride ER 10 mg every morning for urinary retention, both signed out by staff from 1/9/26 through 1/21/26. Review of the hospital discharge records and physician notes showed only a single intended order for Oxybutynin 10 mg daily, not a total of 20 mg per day.

Further review of the resident’s medical record identified that a nephrology consultation completed at the facility by a consultant NP documented that the resident was receiving a duplicate dose of oxybutynin. The consultant NP uploaded her own consultation report with recommendations days after the visit. The DON stated that consultations should go to the unit manager or ADON for review and then be entered by them, and it was reviewed with the DON that the nephrology consultant was uploading her own reports. The DON later reported that the NP acknowledged identifying the medication error but did not bring it to anyone’s attention, stating she did not want to get anyone in trouble.