Failure to Ensure Proper Medication Administration and Documentation
Penalty
Summary
A medication error occurred when a Qualified Medication Aide (QMA) administered a dose of oxycodone 5 mg to a resident with a diagnosis that included lung cancer, after the medication order had been discontinued earlier that day. The QMA did not check the Medication Administration Record (MAR), which would have shown that the pain medication had been discontinued. There was no documentation in the progress notes or on the MAR indicating that the resident received the PRN pain medication on the evening in question, nor was there evidence that the QMA notified a licensed nurse prior to administration, as required by facility policy. The facility's policy and the QMA scope of practice require that a QMA obtain authorization from a licensed nurse before administering PRN medication, document the symptoms and the nurse's authorization, and ensure the record is cosigned by the nurse. In this incident, these steps were not followed. The medication had not yet been removed from the medication cart because only the DON or ADON could oversee its disposal, but the order had been updated in the computer system and reflected on the MAR. The QMA involved had been employed for about a month at the time of the incident.