Failure to Prevent Significant Medication Error and Inaccurate Medication Waste Documentation
Penalty
Summary
A significant medication error occurred when a resident with a history of narcotic dependence, osteoarthritis, joint replacement, spinal stenosis, neuropathy, and post-surgical pain received an extra dose of Pregabalin (Lyrica) within a short time frame. The resident was cognitively intact and on a scheduled pain regimen, including PRN pain medications. On the day of the incident, a Medication Aide administered the resident's prescribed dose of Pregabalin and documented it appropriately. Shortly after, during the Medication Aide's lunch break, an LVN, who had been given the medication cart key, administered an additional dose of Pregabalin to the same resident without verifying the Medication Administration Record (MAR) or the Narcotic Count Sheet. The LVN subsequently filled out a medication waste form, indicating that the medication was wasted, even though it had been administered to the resident. The Medication Aide, upon returning from lunch, signed the waste form without witnessing the medication being wasted and without clarifying what she was signing. This resulted in inaccurate documentation and a failure to follow the facility's policy, which requires two nurses to witness and sign for wasted medications. The incident was discovered after the resident reported receiving two doses of the same medication within a short period and provided video evidence from his room to facility management. Interviews with staff confirmed that the LVN did not check the MAR or narcotic log before administering the additional dose and that the Medication Aide signed the waste form without proper verification. The facility's policy on medication administration and waste was not followed, leading to the resident receiving an extra dose of a controlled medication and improper documentation of medication handling.