Failure to Follow Physician Orders and Proper Technique in Medication Administration
Penalty
Summary
A licensed vocational nurse (LVN) administered the wrong nutritional supplement to a resident by providing Boost Plus instead of the physician-ordered Ensure Plus. The LVN prepared and gave the entire carton of Boost Plus to the resident, despite the clinical record and registered dietitian's note specifying Ensure Plus as the required supplement to address the resident's weight loss and variable oral intake. The LVN later confirmed the error upon review of the resident's order summary report. In a separate incident, a registered nurse (RN) failed to use the push-pause method when flushing another resident's peripherally inserted central catheter (PICC) line with normal saline. The RN flushed the line quickly without the recommended technique, which was confirmed during a follow-up interview. The director of nursing (DON) stated that the push-pause method should be used to maintain the patency of the PICC line, and this was supported by a referenced clinical article.