Failure to Administer Medication per Physician's Order Due to Pharmacy and Nursing Errors
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including a right lower leg infection and a pressure ulcer, was not administered medication according to the physician's order. The resident was prescribed 800 mg of intravenous daptomycin daily, but received 850 mg for two or three doses. The error was traced to the delivery of medication bags from the pharmacy that were intended for another patient at a different facility. The incorrect bags were labeled with another patient's name, which was crossed out and replaced with the resident's name by nursing staff. The medication administration record confirmed that the higher dose was given on at least two occasions. Interviews with nursing staff and the DON revealed that multiple nurses were involved in administering the incorrect medication. One nurse admitted to changing the label on the IV bag and did not realize the dosage discrepancy until later. The facility's investigation indicated that the error was discovered after the pharmacy and another facility reported the delivery mistake. Documentation showed that the medication error was not immediately identified, and the incorrect medication was administered despite the mismatch between the physician's order and the medication label.