Failure to Administer Medication per Physician Order and Incomplete Monitoring After Error
Penalty
Summary
A medication administration error occurred when a resident with diagnoses including anemia, depression, diabetes mellitus, nausea, and hypertension was given 3 mg of lorazepam instead of the prescribed 0.5 mg dose. The error was documented in the resident's progress notes and incident report, which indicated that the resident became lethargic and drowsy following the administration. The Assistant Director of Nursing suggested that the nurse may have confused the resident's dose with another resident's order for lorazepam. Review of the Medication Administration Record (MAR) and controlled substance administration record revealed inconsistencies in documentation, with doses not matching between records and improper notation of a wasted dose instead of recording an error. Following the medication error, physician orders were written to monitor the resident's vital signs twice daily for three days. However, review of the vital sign records showed that no vital signs were recorded for the evening shifts on three consecutive days after the incident. Additionally, there were no nursing progress notes documenting follow-up on the medication error during this period. Interviews with facility leadership confirmed that medication administration protocols and documentation expectations were not followed, and that appropriate disciplinary action and education for the involved nurse had not been confirmed.