Failure to Ensure Nursing Staff Competency in Medication Administration Resulting in Harm
Penalty
Summary
Nursing staff failed to demonstrate the necessary competencies and skill sets for safe medication administration, resulting in a medication error involving a resident with diagnoses including high blood pressure, schizophrenia, and weakness. The resident was administered the wrong medications, including amiodarone, which was not prescribed for them. Following the administration, the resident experienced mild chest pain and shortness of breath, prompting an assessment and subsequent transfer to the emergency department for further monitoring. Documentation revealed that the nurse responsible did not recognize the room as a three-person room at the time of administration and only realized the error after the fact. Facility records confirmed that the nurse involved had previously received education on safe medication administration. However, the incident still occurred, indicating a lapse in following established protocols such as verifying the six rights of medication administration. The event was substantiated through clinical record review, staff interviews, and facility documentation, confirming that the failure to ensure nursing staff competency in medication administration resulted in actual harm to the resident.