"A" VIOLATION(S):

A resident shall not be given unnecessary drugs in accordance with section 330. Appendix e. In addition, an unnecessary drug is any drug used; in an excessive dose, including duplicative therapy.

A resident shall not be given unnecessary drugs in accordance with section 330. Appendix e. In addition, an unnecessary drug is any drug used: in an excessive dose, including duplicative therapy.

This requirement is not met as evidenced by:

Based on record review and interview the facility failed to ensure that 1 of 6 sampled resident(R2) received the correct dosage of medication. R2 received a toxic amount of a medication, resulting in R2's death from cardiac arrhythmia due to medication toxicity.

Findings include:

Review of the admission face sheet confirms that R2 has a diagnosis of congestive heart failure, hypertension and Parkinson's disease. The monthly summary dated 12/8/01 confirms that R2 was alert and oriented, self care, ambulated independently and weighed 136 pound. E2 stated in interview on 1/23/02 at 10:00 a.m. that R2's height was 62 inches. R2 resided on the shelter care hall. E2 confirmed in interview on 1/22/02 at 2:00 p.m. that the nurses administered medications to R2.

E3. LPN(Licensed Practical Nurse) provided the following information during interview on 1/22/02 at 2:40 p.m.: E3 stated that she called Z1's(the physician) office as R2 was complaining of a painful left great toe on 1/14/02. E3 stated that Z2 the physician's nurse had stated that Z1 was out of the office, but that Z2 would give Z1 a condition report when he got back. E3 stated that Z2 called back with an order for R2's foot from Z1 the physician. E3 stated that the order was for Colchicine 6 mg(milligrams)- 6 tablets every hour for 4 hours. E3 stated that she questioned Z2 about whether Z1 wanted to give that many tablets, and that Z2 told her that that was what Z1 wanted to order, and that Z2 had already questioned Z1 about the order. E3 stated that she then called the order to Z3, the pharmacist. E3 stated that Z3 told her that the Colchicine didn't come in 6 mg tablets, but only in 0.6mg tablets. E3 stated that the only concern she had about the Colchicine order was that Z1 had R2 taking 6 tablets at once. E3 stated that she questioned Z3 about having to give so many pills to R2 but that Z3 told her that they were small pills, not to worry. E3 stated that Z3 did not tell her to clarify the order with Z1 or that the order for Colchicine was a excessive dose. E3 confirmed that she did not clarify the order with Z1 or Z2 after finding out from Z3 that Colchicine only came in 0.6mg not 6 mg tablets. E3 confirmed that she had never heard of the medication and that she did not look the medication up in the reference books available.

E4, LPN, provided the following information during interview on 1/22/02 at 3:05 p.m.: E4 stated that she had received report from E3 on 1/14/02. E4 stated that E3 told her that R2 had a new order for Colchicine 0.6mg-6 tablets every 1 hour for 4 hours. E4 stated that she noticed that the physician order sheet stated, Colchicine 6 mg-6 tablets every 1hour for 4 hours, so she called E3 to recheck with her on the dosage of the medication. E4 stated that E3 told her that Z3 had said that the Colchicine only came in 0.6mg. E4 stated that she then changed the physician order to Colchicine 0.6mg. E4 stated that she then went to the pharmacy and picked up the medication so she could start giving it. E4 confirmed that she gave R2 Colchicine 0.6mg-6 tablets at 6:30, 7:30, 8:30 and 9:30 p.m. E4 confirmed that she was not familiar with the medication and did not look it up in the reference book before giving the Colchicine.

The physician order sheet dated 1/14/02 states, "Colchecine .6mg; 6 tabs q[every] hour x[times] 4 hours for gout. D/C[discontinue] if N/V[nausea, vomiting] occurs."

Review of the medication record for 1/1/02 through 1/31/02 confirms that "Colcheciene .6mg, 6 tablets q hour x 4 hours" was given on 1/14/02 at 6:30p.m., 7:30p.m., 8:30 p.m. and 9:30 p.m.

Review of the nurses notes confirm the following entries: 1/14/02 at 2:00 p.m--"Received n.o.[new order] from Z1's office for Colcheciere .6mg, 6 tablets q hour x 4 hours. Res. notified of new order."

1/14/02 at 6:30 p.m.--"Rcd[received] n.o. from pharmacy-Administered per order."

1/15/02 at 2:15 a.m.--"Res rang for staff A[assist]-Res experiencing N & V. Res vomited x 4 in 20 min.-Res v/s[vital signs] 180/100-97.7-104-24. Res skin w/d[warm, dry] -sl. pale."

1/15/02 at 2:40 a.m.--"152/99- 97.7-106-20. Res cont with n/v."

1/15/02 at 2:50 a.m.-The physician was called and given a condition report and ordered Phenergan to be given.

1/15/02 at 4:00 a.m.--R2 was sent to the emergency room for an evaluation.

1/15/02 at 5:35 a.m.--"Noted in PDR[Physician Desk Reference] limit of med to be administered p/day is 10 mg-During conversation with other ns[nurse] realized 0.6mg x 6 x 4 = 14.4mg-"

1/15/02 at 8:25 p.m. a call was received that notified staff that R2 had expired.

Z3 the pharmacist stated in interview on 1/22/02 at 12:05 p.m. that the day the order came in he had questioned the order with E3, and stated that he thought the dose seemed to be excessive. Z3 stated that he questioned the 6 tablets every 1 hour and asked E3 to clarify the order with the physician. Z3 stated that he was sure that E3 had clarified the order with Z1. Z3 stated that E3 called back and stated that she had talked to Z2 and that the Z2 went and asked Z1 if the order was correct. Z3 stated that E3 stated that Z2 stated that Z1 had said he wanted Colchicine 0.6mg-6 tablets every 1 hour. Z3 stated that when E3 first gave him the order that she had said Colchicine 6mg, but that he told her that the Colchicine only came in 0.6mg tablets. Z3 confirmed that he packaged the red cassette with Colchicine 0.6mg-6 tablets in each slot.

Observation of the red plastic cassette on 1/22/02 at 10:25 a.m. confirmed that all the slots in the cassette were empty of medication. The cassette was labeled with a white pharmacy label. The label with R2's name and the date 1/14/02 stated, " Colchicine tab 0.6mg Take 6 tabs q HR x 4HR"

Z1 the physician stated in interview on 1/22/02 at 12:00 p.m. that the office got a call from E3 about R2's pain in the toe. Z1 stated that he gave Z2 the order for Colchicine 0.6mg every hour for 4 hours for R2. Z1 stated that if the Colchicine 0.6mg is given every hour for 4 hours that would usually be the maximum dose. Z1 stated that you would not usually give more that 6 tablets of Colchicine 0.6mg over 6 hours. Z1 stated that Colchicine is not usually given every day.

Z2 the physician's nurse stated in interview on 1/23/02 at 9:00 a.m. that she had received a call from the nursing home about R2 having a painful toe. Z2 stated that she checked with Z1 and that Z1 ordered Colchicine 0.6mg--4 tablets, 1 tablet to be given every hour. Z2 stated that E3 did not question her about the dosage of the medication. Z2 stated that E3 did question her on how to spell the medication and that she did tell E3 how to spell Colchicine.

Review of the Medication Error Report confirms the following information:

The error occurred on 1/14/02 and was reported on 1/15/02. The section of the report labeled "medication as ordered" was "Colchesine 0.6mg-6 tabs q hr x 4 hrs-d/c if n/v occurs." The section of the report labeled "description of error" states, "Nurses did not realize res rec'd to much medication (Colchesine) until 5:30 a.m. The section of the report labeled "Corrective action taken" states, "Sent to St. Mary's E.R. at 0420. Order was question by E3 when received."

The Preliminary Autopsy Report for R2 dated 1/16/02 states, "The most probable cause of death was cardiac arrhythmia as a consequence of medication toxicity due to a overdose of Colchicine." The report states that there is a history of ingestion of a "toxic amount of Colchicine-24 tabs, 0.6mg in 4 hours".