F0760

E

Failure to Clarify Conflicting Carvedilol Orders Resulting in Significant Medication Error

Windsor, North Carolina Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to clarify and correctly implement a carvedilol dosage order for a resident with hypertension, heart failure, and coronary and peripheral artery disease, resulting in a significant medication error. The resident was discharged from the hospital with an order for carvedilol 25 mg by mouth twice daily and admitted to the facility with that same dose ordered for essential hypertension. The Medication Administration Record (MAR) shows that this 25 mg twice-daily dose was administered from 12/3/25 through 12/4/25.

On 12/5/25, the resident was seen by a cardiologist (Physician #2). The cardiology consultation documents contained conflicting information: the handwritten portion recommended increasing carvedilol to 37.5 mg twice daily with a systolic blood pressure goal of 110–130 mmHg; a printed “After Visit Summary Instructions” section stated to increase carvedilol to 3.125 mg twice daily; and a printed medication list specified carvedilol 25 mg, 1.5 tablets (37.5 mg) in the morning and 37.5 mg in the evening. Nurse #12, who was assigned to the resident that day, reviewed these documents, recognized the discrepancy among the handwritten recommendation, the printed instructions, and the medication list, but did not contact a provider for clarification. Instead, she entered an order for carvedilol 3.125 mg by mouth twice daily based on the printed instructions portion, despite knowing she should have called to clarify the conflicting information.

Following this order entry, the MAR shows that carvedilol 3.125 mg twice daily was administered from the evening of 12/5/25 through the end of December and continued into January until 1/7/26. During this period, the resident’s blood pressure was monitored twice daily, with systolic readings ranging from 100 to 180 mmHg in December and 111 to 172 mmHg in early January, and diastolic readings ranging from 48 to 94 mmHg in December and 55 to 87 mmHg in early January. The consulting pharmacist identified the discrepancy between the original 25 mg twice-daily dose, the cardiologist’s recommendation to increase to 37.5 mg twice daily, and the facility’s significantly reduced 3.125 mg twice-daily order during an initial medication regimen review on 12/8/25 and sent a recommendation to the DON to clarify it. The Medical Director later acknowledged that someone at the facility should have identified and clarified the discrepancy, and the DON stated that Nurse #12 should have immediately clarified the carvedilol order when she saw the conflicting information, characterizing the situation as a significant medication error.