Incorrect Dosage of Medication Administered
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer the correct dosage of ferrous sulfate to a resident with anemia, gastrostomy, and chronic obstructive pulmonary disease. The resident, who was totally dependent on staff for care and had severely impaired cognitive skills, had a physician's order for 7.5 ml (330 mg) of ferrous sulfate to be given daily via gastrostomy tube. During a medication pass observation, the LVN administered only 5 ml (220 mg) instead of the prescribed 7.5 ml. The LVN acknowledged during an interview that she did not follow the physician's order and attributed the error to an oversight. The facility's policy and procedure for administering medication requires that medications be given in accordance with prescriber orders. This failure to administer the correct dosage was directly observed and confirmed through interview and record review.