Significant Medication Administration Errors by Licensed Nurse
Penalty
Summary
A Licensed Nurse (E6) failed to administer medications in accordance with physician orders for two residents during observed medication administration. For one resident (R67), the nurse administered both a 20 mg and a 10 mg tablet of Citalopram (Celexa), totaling 30 mg, despite the physician's order specifying only 20 mg daily for Generalized Anxiety Disorder. The nurse confirmed this error during an interview at the time of the finding. For another resident (R32), the same nurse dispensed and crushed Clopidogrel 75 mg and Senna Plus Stool Softener tablets, even though the physician's orders explicitly stated that these medications should not be crushed. The nurse also confirmed this deviation from the orders during an interview. The facility incurred a medication error rate of 11.54% as a result of these incidents.