Significant Medication Error Due to Late Administration and Inaccurate Documentation
Penalty
Summary
A deficiency occurred when a resident with diagnoses including COPD, diabetes, and hypertension did not receive prescribed morning breathing treatments (Albuterol and Budesonide) at the scheduled time. Facility policy requires medications to be administered within one hour of their prescribed time, but the resident did not receive these medications until after noon, despite being ordered for 9:00am. The resident, who is cognitively intact, expressed concern about not receiving her breathing treatments on time, stating their importance for her ability to breathe. Observation of the medication pass confirmed that the LPN administered the medications late and did not notify the physician prior to the late administration. Additionally, review of the Medication Administration Records (MARs) revealed inaccurate documentation, as the LPN recorded the medications as being administered earlier than they actually were. The LPN admitted to not signing out medications at the time of administration, instead documenting them later from notes. These actions resulted in a significant medication error for the resident.