Incorrect Transcription and Dosing of Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and administer a prescribed psychotropic medication for a resident admitted with a mental health disorder. On admission, the provider ordered Seroquel 25 mg to be given once daily in the evening. However, when the order was entered into the Medication Administration Record (MAR), it was incorrectly transcribed as Seroquel 25 mg once a day, give 0.5 mg in the evening. As a result of this incorrect transcription, the MAR reflected administration of only 12.5 mg (½ tablet of a 25 mg tablet) instead of the prescribed 25 mg dose. The MAR for January and February showed that the resident consistently received 12.5 mg of Seroquel every evening from early January through early February, rather than the intended 25 mg dose. A facility investigation documented that the pharmacy dispensed 12.5 mg (½ of a 25 mg tablet) based on the incorrect order, and this dose was administered throughout the period. Interviews with the Resident Care Manager and the DNS confirmed that the original provider order was for Seroquel 25 mg every evening and that the order had been transcribed incorrectly into the MAR, resulting in the resident receiving the wrong dose.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.