Incorrect Depakote Dose Dispensed and Administered Due to Pharmacy Entry Error
Penalty
Summary
Pharmaceutical services failed to provide the correct dose and form of Depakote for a resident with unspecified convulsions/epilepsy. The resident had an active order dated 03/16/25 for Depakote Sprinkle Capsule 125 mg, 2 capsules by mouth three times a day. Instead, the pharmacy dispensed Depakote 500 mg delayed-release tablets, packaged and labeled in Smartpass pouches with instructions to give 2 capsules three times a day to equal 250 mg, which did not match the ordered dose or form. Pharmacy records and packing slips showed multiple deliveries of Depakote 500 mg tablets on three separate dates, each with quantities consistent with ongoing administration of the incorrect medication strength. According to interviews, a pharmacist entered the incorrect Depakote dose into the Smartpass system, and this error was described as human error and a failure by pharmacists to pay attention when entering the order. The incorrect entry then flowed through the automated packaging process, resulting in the wrong medication strength being dispensed and sent to the facility. Nursing notes documented that a nurse was notified by the pharmacist on 04/02/25 that the wrong Depakote dose had been sent. The DON, who was not employed at the time of the incident, stated that while she expected the pharmacy to send the correct medication, dose, and form, it was also the nurse’s responsibility to check all medications against active orders.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.