Significant Medication Errors Due to Improper Administration and Dosage Measurement
Penalty
Summary
Three residents experienced significant medication errors due to failures in medication administration and preparation by licensed nursing staff. One resident with diabetes and moderate cognitive impairment did not receive their prescribed dose of Insulin Lispro before dinner, despite a blood sugar reading that required administration according to the physician's order. The nurse checked the resident's blood sugar but did not return to administer the insulin, and this omission was confirmed by both the resident and facility records. Facility policy required strict adherence to insulin administration protocols, including verification of the correct dose and type, which was not followed in this instance. Another resident, who was completely dependent on staff and had severely impaired cognition, was prescribed Polyethylene Glycol 1450 powder for administration via gastrostomy tube. However, the nurse failed to identify a discrepancy between the medication on hand (Polyethylene Glycol 3350) and the medication ordered by the physician (Polyethylene Glycol 1450). The nurse did not compare the medication label to the order and did not seek clarification from the physician, as required by facility policy. This discrepancy was observed during medication preparation and confirmed by interviews with nursing staff and the interim Director of Nursing. A third resident, also fully dependent and cognitively impaired, was prescribed Psyllium Husk Powder to be administered via gastrostomy tube. The nurse preparing the medication did not use proper measuring tools to ensure the correct dose of fiber powder and water, instead using a plastic spoon and an unmeasured amount of water. When questioned, the nurse was unable to provide correct dosage conversions or explain the importance of accurate measurement. Additional interviews revealed that three sampled nurses were unable to correctly identify basic dosage conversions, further contributing to the risk of medication errors.