Medication Error Due to Failure to Follow Hold Order and Unattended Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow a physician's order to hold the medication Empagliflozin (Jardiance) for a resident with diabetes, hypertension, and atherosclerotic heart disease. The medication was on hold per physician order and family request, as documented in the resident's medical record and medication administration record. Despite the hold order, the LVN attempted to administer the medication during a morning shift and left the medication unattended at the resident's bedside at the request of a family member, intending for the family to administer it after oral care. The LVN acknowledged during an interview that leaving the medication with the family and attempting to administer a medication that was on hold was not standard nursing practice. The registered nurse supervisor confirmed that the medication was on hold and later discontinued, and that the error was discussed with the LVN and the family. The assistant director of nursing also stated that medication administration should be witnessed by licensed staff and that all medication orders, including holds and discontinuations, are clearly visible in the medication administration record. Facility policy and procedure require that medications be administered only as ordered by a physician or licensed independent practitioner, and define a medication error as administering a medication that is not currently prescribed. The LVN's actions in attempting to administer and leaving a held medication unattended constituted a failure to comply with these requirements, resulting in a medication error for the resident.