Failure to Administer IV Medication per Physician Order and Standards
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including a right lower leg infection and a pressure ulcer, was not administered intravenous daptomycin according to the physician's order. The resident was ordered to receive 800 mg of daptomycin IV daily, but nurses administered 850 mg IV daily using medication bags that were incorrectly labeled with another patient's identifiers. The error was discovered after the pharmacy notified the facility that medication intended for another patient at a different facility had been delivered in error. Nurses had crossed out the original name on the IV bags and relabeled them with the resident's name without verifying the correct dosage or patient information. The facility failed to thoroughly investigate the medication error, as it was unclear exactly how many incorrect doses were administered and which nurses were involved. Documentation showed that at least one incorrect dose was given, and two remaining bags were removed from the fridge after the error was identified. Interviews revealed that staff did not consistently check medication labels or dosages before administration, and the process for accepting and verifying pharmacy deliveries was not adequately followed. The facility did not ensure that the resident's IV medication was administered according to accepted standards of clinical practice.