Failure to Identify Incorrect Antipsychotic Order During Monthly Drug Regimen Review
Penalty
Summary
The deficiency involves the facility’s failure to identify and correct an inaccurately transcribed antipsychotic medication order during the monthly medication regimen review for one resident. The resident had diagnoses including paranoid schizophrenia and a cognitive communication deficit and was admitted with an existing regimen of Haloperidol Decanoate injections every 21 days. On admission, an LPN entered the Haldol order into the electronic medical record incorrectly as an intramuscular injection to be given daily from the 16th through the 21st of each month, with additional directions stating every 21 days. This transcription error resulted in the order appearing as multiple consecutive daily doses instead of a single dose every 21 days. The consulting pharmacist completed medication regimen reviews on two occasions and documented that there were no new irregularities in the resident’s medication regimen. During interview, the pharmacist acknowledged noticing that the Haldol injection was scheduled for multiple days in a row but assumed this was to allow nurses flexibility if the medication did not arrive on time, and therefore did not report or question the order. As a result, the incorrect order remained in place and was not identified as an irregularity during the monthly drug regimen review, despite the conflicting directions and the unusual frequency for a long-acting antipsychotic injection. According to the medication administration record, the resident received multiple doses of Haloperidol Decanoate under the incorrect order, with injections documented on several days within the same week. One LPN reported administering two doses and stated that he had questioned the order and asked his unit manager for clarification but was instructed to administer the medication as written. The resident’s family member later reported being informed by the local mental health authority that the resident had received three doses of her monthly Haldol injection in error at the facility. The mental health authority nurse documented a telephone conversation with the LPN in which he confirmed that the resident had received multiple doses within a week based on the written order. The facility’s failure to detect and correct the erroneous order during the pharmacist’s monthly medication regimen review led to the unnecessary administration of an antipsychotic medication.
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