Failure to Notify Resident, Physician, and Representative of Medication Error
Penalty
Summary
The facility failed to notify a resident, her legal representative, and her physician of a medication error involving the administration of Dilaudid. The resident, who had diagnoses including quadriplegia, stage four wounds, osteomyelitis, severe malnutrition, anxiety disorder, depression, and cachexia, was cognitively intact and had a Power of Attorney. According to the medical record and medication administration records, an agency LPN administered twice the prescribed dosage of Dilaudid at two separate times. The error was discovered during a narcotic count at shift change, and it was documented that the nurse had given an extra total of 8 mg of Dilaudid. Despite the facility's policy requiring immediate notification and documentation to the resident, physician, and family in the event of a medication error, there was no evidence in the medical record or progress notes that any of these parties were notified. The DON confirmed that although the physician was verbally informed, this was not documented, and there was no record of notification to the resident or her legal representative. The lack of documentation and notification constituted the deficiency.