Failure to Notify Provider of Medication Error
Penalty
Summary
A medication error occurred when a nurse administered a resident's roommate's medication, specifically Tylenol, to the resident without a request. The resident, who had a history of multiple medical conditions including an open abdominal wound, stage 3 pressure ulcer, and cardiac issues, did not experience any negative effects and was cognitively intact at the time of the incident. The nurse became distracted during the medication pass, which led to the error. The incident was reported to the Director of Nursing (DON), who confirmed that there was no documentation indicating that the resident's provider was notified about the medication error. Interviews with facility staff and the resident's provider revealed that the provider was not informed of the medication error, despite facility policy requiring prompt notification of the resident, physician, and representative when there is a change in status or condition. The DON and Regional Nurse Consultant acknowledged the lack of a specific policy for medication error notification but stated that such incidents should be treated as a change in condition. The provider expressed an expectation to be notified of all incidents involving her patients, but no notification was made regarding this event.