Medication Administration Error and Failure to Reconcile Controlled Substances
Penalty
Summary
A medication administration error occurred when a nurse administered Zolpidem (Ambien), a hypnotic, instead of the ordered Hydrocodone-Acetaminophen 5-325 mg for pain to a resident on two separate occasions. The resident, who had multiple medical conditions including rib fractures, severe malnutrition, cognitive impairment, and chronic pain, was admitted with orders for both pain and sleep medications. The nurse failed to correctly identify and administer the prescribed pain medication, instead giving the resident Ambien, which was not intended for pain management. The facility's policy required nurses to verify medications three times before administration and to reconcile controlled substances at each shift change. However, the nurse did not follow these procedures, resulting in the administration of the wrong medication. The error was not detected during the required narcotic count and reconciliation at the shift change, as the counts of both Ambien and Hydrocodone-Acetaminophen did not match the documentation. The discrepancy was only discovered later when another nurse reviewed the narcotic records and noticed the error. As a result of the medication error, the resident experienced uncontrolled pain, altered mental status, and agitation, ultimately requiring transfer to the hospital for evaluation and treatment. The incident highlighted failures in medication administration, verification, and controlled substance reconciliation, as well as lapses in communication and documentation among nursing staff.