Medication Administration Error Due to Failure to Remove Discontinued Medication
Penalty
Summary
A deficiency occurred when a nurse failed to follow professional standards of nursing practice during medication preparation and administration for a resident. The nurse retrieved and administered Meloxicam 7.5 mg from a medication card that had been discontinued, instead of the current order for Meloxicam 15 mg once daily. The discontinued medication card was not removed from the medication cart after the physician changed the order, leading to the administration of the incorrect dose. The nurse did not reconcile the medication dosage against the physician order prior to administration. Interviews with facility staff revealed that there were multiple medication cards for both the discontinued and current dosages in the cart, and that audits of medication administration and cart storage were performed without consistently checking for discontinued medications. Documentation of medication pass audits was incomplete, lacking details such as dates, resident names, or specific medications observed. Professional standards, including the six rights of medication administration, were not consistently followed, resulting in a medication error for the resident.