Medication Transcription Error Leading to Incorrect Primidone Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to the administration of Primidone for essential tremor. The resident was admitted with diagnoses including type 2 diabetes, kidney disease, urinary tract infection, and essential tremor, and had a BIMS score of 8/15 indicating moderate cognitive impairment. A hospital discharge order dated 12/11/2025 directed Primidone 50 mg, 2 tablets by mouth, twice daily. However, the order entered into the facility’s EMR and reflected on the MAR from 12/11/2025 through 01/07/2026 was for Primidone 50 mg, 1 tablet by mouth, twice daily. MAR review confirmed that staff administered only 1 tablet twice daily during this period, contrary to the hospital discharge order. The error was identified after a family member, who had been contacted by the facility about the resident’s increased tremors, inquired about the Primidone dosage and discovered the discrepancy between the hospital order and the MAR. The resident’s care plan, revised on 01/07/2026, documented that the resident had a medication error related to Primidone. Interviews confirmed that Primidone was being used to treat the resident’s tremors and that the incorrect dose had been transcribed into the MAR at admission. Facility policies required verification of medication name, dose, route, and time against the MAR and correction of discrepancies, as well as monitoring for medication errors and changes in dose, but these processes did not prevent or detect the incorrect Primidone dosage for this resident during the specified time frame.
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