Medication Administration Error Due to Staff Miscommunication and Policy Deviation
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competencies in medication administration, resulting in a medication error involving one resident. On the date of the incident, a nurse (LN 3) prepared medications intended for one resident but handed them to another nurse (LN 4), who was a new graduate and in orientation. Due to miscommunication, LN 4 administered the medications to the wrong resident, giving a full set of 17 medications prescribed for a different resident to the affected individual. The medications included blood pressure medications, blood thinners, seizure medications, pain medications, and other treatments not prescribed for the recipient. The error occurred in a shared room where the two residents had similar medical histories, including conditions such as cerebral infarction, hypertension, hemiplegia, and hemiparesis. LN 3 labeled the medication cup with the intended resident's name but did not personally administer the medications, instead instructing LN 4 to do so. LN 4 misunderstood the instructions and gave the medications to the wrong resident. The error was discovered when the intended recipient noticed discrepancies in her medication cup and reported it to the staff. Interviews with staff revealed that the process of one nurse preparing medications for another to administer was not in accordance with facility policy or standard medication administration protocols, which require verification of the five rights (right resident, right drug, right dose, right route, right time). The facility's policy explicitly states that medications ordered for a particular resident may not be administered to another resident, and that the individual administering medications must verify the resident's identity and check the medication label three times.