Medication Administration Errors Involving Two Residents
Penalty
Summary
Two residents were not provided with safe administration of medications as required by facility policy. One resident, who had diagnoses including diabetes, COPD, and epilepsy and a BIMS score indicating moderately impaired cognition, had a physician's order for 81 mg enteric coated (EC) aspirin daily for DVT prophylaxis. Instead, the resident was administered an 81 mg chewable aspirin tablet, which did not match the prescribed form. The error was identified when the medication order was reviewed and it was found that the order had been transcribed incorrectly due to the facility not carrying the capsule form, and the original order specified EC aspirin. Another resident, with a history of acute gastrojejunal ulcer with perforation, pain, and a gastrostomy and a BIMS score indicating intact cognition, had a physician's order for a 4% lidocaine patch to be applied to the back at bedtime and removed in the morning. During a medication pass, an LPN applied the patch to the resident's left knee instead of the back and at the wrong time of day. The DON confirmed that the patch should have been applied to the back at bedtime and removed in the morning, as per the order.