Improper Measurement of Medication Dosage During Administration
Penalty
Summary
A deficiency occurred when a registered nurse prepared a resident's medication using an unlabeled white eating utensil spoon to scoop Benefiber powder from a bulk bottle, rather than using a measurement-labeled device as required. The nurse mixed two scoops of the powder in a measured cup before adding liquid, despite the physician's order specifying the administration of either one packet or two teaspoonsful of Benefiber powder dissolved in eight ounces of liquid. The use of an unmeasured utensil did not ensure the correct dosage was given, as the utensil was not marked for accurate measurement. The facility's policy and procedures for medication administration require that liquid medications be measured using a graduated medication cup or an appropriate measurement-labeled device. During interviews, the DON confirmed that staff are expected to use proper measuring devices for medication preparation. The surveyor's observations and record reviews confirmed that the nurse did not follow these protocols, resulting in a significant medication error for the resident.