Failure to Administer Ordered Steroid Injection Resulting in Significant Medication Error
Penalty
Summary
A deficiency occurred when the facility failed to ensure a one-time dose of methylprednisolone (a steroid) intramuscular injection, prescribed for the treatment of an allergic reaction, was administered as ordered. The resident, who had a history of heart failure and chronic pain, developed an itchy, erythematous rash with hives and a low-grade fever after being treated with clindamycin for a gum abscess. The nurse practitioner (NP) discontinued clindamycin and prescribed alternative medications, including oral and topical treatments, but as the rash worsened, the NP ordered a one-time intramuscular injection of methylprednisolone. Despite the order, the injection was not administered for five days. Nurse #1, who was responsible for giving the injection, did not find the medication on the cart and was incorrectly informed by another nurse that it was not available in the backup medication supply. Although the backup supply did contain the medication, Nurse #1 did not access it and instead passed the responsibility to the oncoming nurse, assuming the medication would be administered once delivered by pharmacy. The medication remained unadministered until the NP discovered the omission during a subsequent visit and directed that the injection be given. Interviews with facility staff, including the Director of Pharmacy Operations, confirmed that the medication was available in the backup supply and had not been removed or administered as ordered. The Director of Nursing and Administrator acknowledged that the nurse should have checked the backup supply and administered the medication as ordered. The resident continued to experience significant discomfort, including widespread rash and severe itching, during the delay in administration.