Significant Medication Errors Due to Late and Improper Administration
Penalty
Summary
A licensed nurse failed to ensure that a resident was free from significant medication errors by administering morning medications more than one hour late, leaving the medications unattended at the resident's bedside, and omitting an important medication that was required to be given with breakfast. The resident, who had a history of hemiplegia and hemiparesis following cerebrovascular disease, was observed with a cup containing nine medications left on her bedside table after 10 a.m., and she reported that one medication was missing. The nurse confirmed both the late administration and the omission of metformin, which was supposed to be given with breakfast. A review of the resident's Medication Administration Record showed that all scheduled morning medications were to be administered at 8 a.m. or 9 a.m., with none scheduled for 10 a.m. or later. The nurse acknowledged that breakfast was served between 8 a.m. and 8:30 a.m., and that the medications, including those requiring administration with food, were given outside the prescribed time window. Facility policy required medications to be administered within one hour before or after the scheduled time, and the Director of Staff Development confirmed that deviations from this protocol constituted medication errors.