Discontinued Medication Administered Due to MAR Verification Failure
Penalty
Summary
A medication error occurred when a qualified medication aide (QMA) administered a dose of oxycodone to a resident after the medication had been discontinued. The resident, who had diagnoses including lung cancer, was prescribed oxycodone 5 mg every four hours as needed for pain, with the order starting on 7-9-25 and discontinued on 7-16-25 at 11:45 a.m. Despite the discontinuation being reflected in the medication administration record (MAR), the QMA did not check the MAR before administering the medication on the evening of 7-16-25. There was no documentation in the MAR or progress notes of the medication being given at that time, but the Controlled Drug Receipt Record/Disposition Form confirmed the administration. The error was identified the following day, and it was noted that the medication had not yet been removed from the medication cart because only the DON or ADON are authorized to dispose of medications. The QMA involved had been employed for about a month at the time of the incident. The facility's director of nursing confirmed that this was the only medication error since the most recent annual survey and attributed the error to the staff member's failure to verify the MAR, which would have shown the medication had been discontinued.