Failure to Check Required Parameters Before Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) prepared to administer Gabapentin to a resident without first checking the resident's respiration rate as required by the physician's order. The resident, who had diagnoses including dementia, neuralgia, and neuritis, was observed in a recliner wheelchair as the LVN prepared the medication by mixing Gabapentin with applesauce. The LVN was about to administer the medication when a surveyor intervened and asked the LVN to stop. Upon review, the Medication Administration Record (MAR) indicated that Gabapentin should be held if the resident's respiration rate was less than 12, and the physician should be notified. The LVN admitted that the respiration rate had not been checked immediately prior to administration, as required, but claimed it had been checked 15 minutes earlier without documentation. The Director of Nursing (DON) confirmed that checking parameters such as respiration rate is a required part of the physician's order and that failure to do so constitutes a significant medication error. Facility policy defined a medication error as the preparation or administration of drugs not in accordance with the physician's order. The policy also stated that staff should strive to minimize adverse consequences resulting from medication errors. The incident was identified through observation, interview, and record review, and it was determined that the failure to check the resident's respiration rate immediately before administering Gabapentin was a significant medication error.