Failure to Prevent Significant Medication Error and Incomplete Documentation
Penalty
Summary
A resident with multiple complex medical conditions, including quadriplegia, stage four wounds, osteomyelitis, severe malnutrition, anxiety, depression, and cachexia, was admitted to the facility and had intact cognition. The resident had a physician's order for Dilaudid 4 mg to be administered four times daily for chronic pain. On two occasions, an agency LPN administered twice the prescribed dosage of Dilaudid, giving an extra 4 mg at both the midnight and morning doses, resulting in a total of 8 mg extra being given. This medication error was discovered during a narcotic count at shift change. Review of the facility's documentation revealed that the medication error was not recorded in the resident's progress notes for the days following the incident. Additionally, although the DON stated that the physician was notified of the error, there was no documentation to confirm this communication. The facility's policy required all medication errors to be appropriately documented and tracked, but this was not followed in this instance.