Medication Administration Error and Failure to Document
Penalty
Summary
Facility staff failed to administer medications as ordered by the physician when an LPN prepared insulin intended for one resident, but the ADON administered it to a different resident who did not have a physician's order for insulin. The medication administration policy required staff to verify the right resident, medication, dosage, time, and route before administration, and to document any medication errors in the clinical chart. However, the insulin was prepared for one resident and given to another, and there was no documentation of this medication error in the resident's medical record. The resident who received the insulin was assessed as cognitively intact and had diagnoses including Alzheimer's, hypothyroidism, congestive heart failure, schizophrenia, and diabetes mellitus type II, but did not have a current physician's order for insulin. The error was discovered when the resident's family questioned the administration of insulin, leading to notification of the physician. Interviews revealed that staff were aware of the error but failed to document it as required, and that medication preparation and administration were improperly split between staff due to staffing shortages.