Medication Administration Error for a Resident
Penalty
Summary
The facility failed to provide medications as ordered by the physician for a resident, identified as Resident 41. The resident, who was cognitively intact and required moderate assistance for daily care, had a diagnosis of high blood pressure. According to the physician's orders dated February 4, 2025, the resident was to discontinue taking 5 mg of amlodipine and start taking 5 mg of lisinopril. However, during a medication administration observation on February 5, 2025, an LPN administered 5 mg of amlodipine instead of the prescribed lisinopril. The LPN was observed dropping the amlodipine tablet on the cart, picking it up with bare hands, and then administering it to the resident. The LPN confirmed the error and acknowledged that medications should not be handled with bare hands. The Medical Director was notified of the medication error, and new orders were issued to hold the lisinopril for one day. The Nursing Home Administrator was informed of the incident and confirmed the improper handling of the medication.
Plan Of Correction
1. Resident 41 meds were reviewed for accuracy. 2. A house audit was conducted to review and reconcile resident medications for discontinued discrepancies. None were found. 3. The process was changed, and nurses were educated so that the person taking the discontinued order goes to the cart and removes the discontinued medication. During clinical review each morning, a list of discontinued medications will be reviewed and given to the RN supervisor to verify accuracy of cart medications. 4. An audit of discontinued medications against cart accuracy will be done weekly x 4 and then monthly x2 and reported to the Quality Assurance team for review. The Director of Nursing or designee will monitor.