Failure to Transcribe and Administer Ordered Psychotropic Medication
Penalty
Summary
Surveyors identified that the facility failed to ensure a resident was free from significant medication errors related to a psychotropic medication. Pennsylvania Code Title 49, Section 21.11, which outlines RN responsibilities for promoting, maintaining, and restoring well-being and being accountable for the quality of care delivered, was cited. Facility policies titled "Medication and Treatment Orders" and "Medication Errors" required that newly prescribed medications, including written transfer orders from other health care facilities, be clarified if unclear and transcribed onto the Medication Administration Record (MAR) or electronic MAR, and that medications be administered according to physician orders. Review of the clinical record for Resident R1, admitted on 1/8/26 with schizoaffective disorder bipolar type, Parkinson’s disease, and major depressive disorder, showed that the facility’s physician orders dated 1/8/26 did not include an order for lithium 300 mg extended-release orally, despite this medication being present on the transfer orders. As a result, the resident did not receive lithium carbonate 300 mg from 1/8/26 through 2/8/26. During an interview, the DON confirmed that the lithium order from the transfer documentation was not transcribed into the resident’s medication record, was not clarified with the physician, and therefore was not administered as ordered.
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