Medication Administered Without Physician Order
Penalty
Summary
A medication administration error occurred when a licensed vocational nurse (LVN) gave a resident four tablets of melatonin, totaling 12 milligrams, without a physician's order. The resident, who had end stage renal disease and was dependent on dialysis, was admitted with intact cognition and the ability to make decisions. The error was documented in the resident's records, including the Change in Condition Evaluation and Care Plan Report, which noted the risk for possible adverse reactions and the need for monitoring. The facility's policy and procedure for administering medications requires that medications be given as prescribed, but this was not followed in this instance. The incident was validated through interviews and record reviews, including statements from the resident and the Director of Nursing (DON). The LVN admitted to administering the melatonin upon the resident's request without verifying a physician's order. The facility's policy, reviewed with the DON, clearly states that medications must be administered in accordance with prescriber orders, which was not adhered to in this case.