Significant Medication Errors Due to Duplicate Orders and Improper Administration
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration and order management. One resident with Alzheimer's disease, dementia, and depression, who was severely cognitively impaired and dependent on staff, received a double dose of Baclofen for three consecutive days. This occurred after duplicate physician orders for Baclofen 2.5 mg once daily were entered on consecutive days, resulting in the medication being administered twice daily instead of once. The error was not identified or questioned by the LPN administering the medication, who assumed the dosage had been increased and did not seek clarification, leading to the resident receiving 5 mg daily instead of the prescribed 2.5 mg. Another resident with Alzheimer's disease, ataxia, and hypertension, who also had severe cognitive impairment and required supervision for meals, was administered Nifedipine ER 30 mg in a crushed form, despite a clear warning on the medication packaging not to crush the extended-release tablet. The nurse did not have a physician order to crush the medication and was unaware of the warning. Additionally, the same nurse failed to administer a prescribed dose of guaifenesin cough syrup but documented in the Medication Administration Record that it had been given. Interviews with nursing staff and management confirmed that proper procedures were not followed in both cases. Duplicate orders were not clarified or discontinued, and medications were administered and documented incorrectly. The facility's policy required physician orders for crushing medications and proper administration techniques, which were not adhered to in these instances.