Double Dosing of Blood Pressure Medication Due to Documentation and Assignment Errors
Penalty
Summary
A deficiency occurred when a resident with a history of cardiac arrest was administered a double dose of Metoprolol Tartrate, a blood pressure medication, by two different licensed vocational nurses (LVNs). The first LVN administered the medication but was interrupted before documenting the administration. Upon returning, the LVN discovered that a second LVN had also administered the same medication, mistakenly believing the resident was assigned to him. The second LVN did not verify his assignment prior to giving the medication, and both LVNs found that the medication was present in both of their medication carts. Review of the Medication Administration Record (MAR) showed that only one administration was documented, and the facility's policy required immediate documentation after medication administration. Both the Administrator and the Director of Nursing confirmed that the policy was not followed, and the staff failed to adhere to the five rights of medication administration and proper documentation procedures.