Medication Administration Error Due to Failure to Follow Protocols
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders, resulting in a medication error involving one resident. A resident with a history of cerebral infarction and hypertension was incorrectly given her roommate's medications, which included a total of 17 different drugs not prescribed for her. This error was discovered during a review of the resident's progress notes and care plan, which documented the administration of medications intended for another resident who had hemiplegia and hemiparesis following a cerebral infarction. The incident occurred when a nurse (LN 3) prepared medications for one resident and labeled the medication cup accordingly, then handed the cup to another nurse (LN 4), who was new and in training. Due to a miscommunication, LN 4 administered the medications to the wrong resident. LN 4 believed she was giving the medications to the correct person based on instructions, but later realized the error after the intended recipient questioned the contents of her medication cup. Interviews with staff revealed that the process of one nurse preparing medications for another to administer was not standard practice and contributed to the error. Further interviews with facility staff and the consultant pharmacist confirmed that proper medication administration protocols were not followed, specifically the verification of the five rights (right resident, right drug, right dose, right route, right time). The facility's pharmacy policy also required that medications be administered directly to the intended resident by the person who prepared them, which was not adhered to in this case.