Significant Medication Error Due to Unordered Aspirin Administration
Penalty
Summary
A facility failed to ensure that a resident was free from significant medication errors when an agency LPN administered multiple doses of 81mg chewable aspirin without a provider's order. The resident, who had a history of myocardial infarction and heart disease and was assessed as mildly cognitively impaired, began experiencing chest pain late in the evening. The LPN gave a total of 324mg of aspirin in 81mg increments every five minutes while simultaneously calling 911, despite the resident already having received their prescribed daily dose of 81mg aspirin that morning. There were no standing or emergency orders in place for additional aspirin administration for chest pain. The LPN stated that their agency training directed them to begin an aspirin protocol for chest pain, but acknowledged that no physician order was obtained prior to administering the medication. Facility leadership, including the Administrator and DON, confirmed that there was no facility protocol authorizing this action and that a physician should have been contacted before administering any additional medication. The incident was documented in the nursing progress notes and confirmed through staff interviews and record review.