Medication Administration Error Due to Incorrect Medication Selection
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality during a recertification survey. This deficiency was identified when a Licensed Practical Nurse (LPN) administered incorrect medications to a resident. Specifically, the LPN gave a resident a [MEDICATION NAME] 50 mg-500 mg tablet and a [MEDICATION NAME] Silver Ultra Men's tablet instead of the prescribed [MEDICATION NAME] Silver 0.4 mg-300 mcg-250 mcg tablet. The error occurred because the LPN did not find the correct medication in the medication cart and mistakenly selected a medication intended for another resident. The LPN admitted to signing off on medications before administering them, intending to give all medications at the same time due to the preference of multiple residents. The LPN was unaware that the correct medication was listed under a different name in the medication cabinet. The Registered Nurse and Medical Director confirmed that signing off on medications before administration is not acceptable practice. The Director of Nursing stated that the LPN had received medication administration competency training and there were no prior concerns with their performance.
Plan Of Correction
Plan of Correction: Approved April 25, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F658** I. Immediate Corrective Action: 1) On 3/26/2025 Resident # 320 was assessed by the MD/NP and no adverse effects of receiving late administration of [MEDICATION NAME] and the administration of a different type of [MEDICATION NAME] were noted. 2) On 03/26/25 a medication error report was developed by the DON for this incident and shared with Pharmacy Consultant and Medical Director. 3) On 4/1/25 the DON issued a disciplinary action for LPN# 3 responsible for the medication error. 4) On 4/1/25 a Medication competency was conducted by the RNS for LPN #3. II. Identification of Others: 1) The DON obtained a printout from the EMR for all residents scheduled to receive medications prior to the daily standard 10 am medication time. This list will be utilized by Unit RNS and DON to conduct unit rounds to determine if residents are receiving medication timely and accurately. Any issues will be immediately corrected. 2) The DON obtained a list of all residents receiving [MEDICATION NAME]. This list will be utilized by the DON and Medical Director to ensure appropriately prescribed [MEDICATION NAME] vitamin doses are ordered and received. Any issues will be immediately corrected. III. Systemic Changes: 1) The DON, Medical Director and Administrator in conjunction with the Pharmacy Consultant reviewed the Facility policies/procedures for medication administration and found same to be compliant. The P/P will be in serviced to all Licensed Medication nurses by the Inservice Coordinator. The Lesson plan will focus on: - Standard for safe medication practices: The Rights of Medication Administration that include: - Right patient - Right drug - Right dose - Right route - Right time - Right reason - Right Monitoring (including vital signs and observation for side effects) - Right documentation - Right patient education - Right evaluation - Right to refuse. - Types of Medication Errors - Medication Documentation and communication. IV. Quality Assurance: 1) The DON will develop an audit tool to monitor compliance with ensuring compliance with standards of practice for Medication Administration. 2) The audit will be done by the DON/Designee on 4 randomly selected medication nurses on random shifts weekly x 4 weeks, followed by 4 randomly selected medication nurses monthly x 6 months. 3) All Nurses will continue to have a Medication Competency upon hire and annually completed by the Inservice Coordinator/Designee. 4) Results from the audit will be brought to the Quarterly QA Meeting to monitor compliance and track sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025 - Director of Nursing