Failure to Administer Prescribed Medication as Ordered
Penalty
Summary
A deficiency occurred when a nurse (ADON) failed to administer a resident's prescribed Magdelay (magnesium chloride supplement) as ordered. The resident, an elderly female with diagnoses including dementia, hypertension, muscle weakness, and osteoporosis, had an active order for Magdelay 64mg once daily. On the observed date, the ADON prepared and administered a tablet of sloMg instead of the ordered Magdelay. The sloMg bottle had different active ingredient amounts and was not the correct medication or dosage as prescribed. The ADON relied on a handwritten note on the bottle and did not verify the medication or clarify the order with the physician before administration. Interviews with the ADON, DON, and Administrator confirmed that the medication was not administered as ordered and that the nurse was responsible for ensuring accuracy and clarifying any discrepancies. The facility's policy required medications to be administered as prescribed and in accordance with regulations. The error was identified through observation, record review, and staff interviews, which revealed that the resident received an incorrect medication and dosage due to failure to follow proper medication administration procedures.