Significant Medication Errors Due to Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first case, a resident with a history of stomach cancer and a surgically placed J-tube was admitted with orders specifying that medications should be given by mouth. Despite this, nursing staff administered medications through the J-tube, which led to the tube becoming clogged. The resident required transfer to the emergency room, where it was confirmed that the medications had been given via the incorrect route, necessitating surgical replacement of the J-tube. The facility's review found that the admission orders were not properly clarified, and staff did not verify the correct route of administration as required by the facility's medication administration procedure. In the second incident, another resident with multiple diagnoses, including fractures and lymphoma, was found to be wearing two Fentanyl transdermal patches instead of the ordered single patch. The error was discovered during a review, and it was determined that an agency nurse had applied a second patch without removing the first, failing to follow the facility's protocol for medication administration. The physician was notified, and the resident was monitored for signs of oversedation. Both incidents demonstrate failures by nursing staff to adhere to the facility's established procedures for verifying medication orders and following the eight rights of medication administration.