Medication Error: Wrong Antihistamine Administered
Penalty
Summary
A deficiency occurred when a licensed vocational nurse administered cetirizine 10 mg to a resident instead of the physician-ordered loratadine 10 mg. The resident, who had diagnoses including Type 2 Diabetes Mellitus, acute osteomyelitis of the left ankle and foot, and cellulitis of the left lower limb, was admitted and readmitted to the facility with intact cognition. The physician's order specifically required loratadine 10 mg by mouth once daily for skin allergy, but during a medication pass, the nurse gave cetirizine, which was not ordered for the resident. The nurse explained that cetirizine was administered because it was the house supply provided by the pharmacy, despite the absence of a physician's order for cetirizine. The Director of Nursing confirmed that the order was for loratadine and that cetirizine should not have been given. Facility policy required medications to be administered as prescribed and for staff to verify the correct medication, dose, and resident before administration. The error resulted in a medication error and had the potential to cause adverse side effects for the resident.
Plan Of Correction
F755: Pharmacy Services/Procedure/Pharmacist/Records CORRECTIVE ACTION: On 4/17/25, Resident 27 was assessed by a licensed nurse and no adverse reaction was noted. Change of Condition for the Medication Error was initiated and MD was made aware with no new order but to continue to monitor resident. Resident was monitored for 3 consecutive days with no adverse reaction noted related to medication error. On 04/17/25, Medication Cart was supplied with Loratadine. LVN 4 is no longer working at the facility. OTHER RESIDENTS AFFECTED IDENTIFICATION All Residents had the potential to be affected by the deficient practice. On 04/17/25, an audit of all Medication Carts for availability of over-the-counter medications for residents with orders for its use was conducted. All over-the-counter medications were available and none were identified to be affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES Inservice was initiated on 04/17/2025 by DON regarding proper medication administration as ordered by MD. On 04/17/2025, DON/Designee initiated a weekly medication administration observation to 2 random nurses to ensure administration of correct medication as ordered by MD. Medical record will include in the daily audit the MAR for any missed dose of medications ordered by MD. MONITORING PERFORMANCE DON/Designee will report findings from weekly medication administration observation and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.