Duplicate Parkinson’s Medication Orders Not Clarified on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record for a resident receiving carbidopa-levodopa for Parkinson’s disease. The facility’s policy on Medication Administration requires that all current drugs and dosage schedules be accurately recorded on the MAR and that licensed or otherwise authorized staff prepare, administer, and record medications. For this resident, the Order Summary Report showed a physician’s order dated 1/14/26 for carbidopa-levodopa 25-100 mg, two tablets by mouth daily. However, review of the January 2026 MAR revealed two active physician orders for the same medication and dose, one dated 11/25/25 and another dated 1/14/26, both scheduled for administration at 0900. During an interview and concurrent record review, an LVN confirmed that she administered carbidopa-levodopa 25-100 mg, two tablets at 0900, and verified that there were duplicate orders with different dates on the MAR. She stated that she should have clarified these duplicate orders with the resident’s physician but had not done so. In a separate interview and concurrent record review, the DON also verified the presence of the duplicate orders and the inaccuracy in the medical record. The report states that this failure had the potential for the resident’s care needs not being met because the medical information was inaccurate.
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