Failure to Administer Correct Dose of Controlled Medication
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of an incorrect dose of a controlled medication to a resident. Facility policy required that medications be administered according to prescriber orders, with staff verifying the right resident, medication, dosage, time, and method of administration. For a resident with dementia who was receiving hospice services, physician orders specified that 10 mg of diazepam gel should be administered every two hours as needed for agitation, using two 0.5 ml syringes per dose. Review of the controlled drug record revealed that, on multiple occasions, staff signed out and administered only one 0.5 ml syringe of diazepam instead of the prescribed two syringes. This discrepancy was confirmed by the Nursing Home Administrator, who acknowledged that staff had not followed the prescribed dosing instructions on several documented dates and times. The failure to administer the correct dose constituted a significant medication error for the resident involved.