Medication Administration Errors Due to Failure to Verify Orders and Vital Signs
Penalty
Summary
A deficiency occurred when a nurse administered three antihypertensive medications—Bumetanide, Carvedilol, and Losartan—to a resident with a history of hypertension, congestive heart failure, and a cardiac pacemaker without checking the resident's vital signs prior to administration. The nurse stated she relied on CNAs to check vital signs and did not verify them herself before giving the medications. The facility's policy required verification of vital signs before administering such medications, especially for residents with complex cardiac histories. In a separate incident, another nurse applied a topical pain reliever (Biofreeze gel) to a resident's knees without a physician's order. Upon review, the nurse confirmed there was no order for the medication and acknowledged the error. The resident had a history of immune system disorders, and the facility's policy specified that medications must be administered only as prescribed and after confirming there are no known allergies or contraindications. Both incidents were confirmed by the Director of Nursing during interviews and record reviews.