Failure to Ensure Nursing Competency in Emergency Medication Administration
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to demonstrate competency in responding to a resident experiencing severe hypoglycemia. The resident, who had a history of diabetes mellitus, end-stage renal disease, and other chronic conditions, was found lethargic with a blood glucose level of 49, which later dropped to 33. Instead of following the physician's order to administer Baqsimi (Glucagon) nasal spray for low blood sugar, the RN incorrectly assembled and administered an epinephrine auto-injector with a nasal spray cap, intended for Narcan, and delivered it nasally to the resident. The RN did not verify the medication before administration and was unfamiliar with the emergency medications in the facility's E-Kit. The incident was witnessed by another nurse, who assisted in retrieving the emergency kit and observed the incorrect assembly and administration of the medication. The RN initially misrepresented the events but later admitted to not checking the medications and being unfamiliar with their use. Documentation and interviews confirmed that the resident did not receive the ordered Glucagon, and the error was only discovered after emergency medical services arrived and found the epinephrine pen with the nasal spray cap in the resident's bed. The resident was unresponsive when EMS arrived and required intravenous glucose administration to stabilize blood sugar levels. The physician and medical director were not initially informed of the medication error, only of the hypoglycemic episode and hospital transfer. The facility's investigation and staff interviews revealed a lack of competency in medication administration and failure to follow professional standards and physician orders, resulting in a significant medication error affecting the resident's care.
Removal Plan
- All nurses were educated on the use of Emergency Medications by DON.
- Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
- DON, LPN, and RN, ADON reviewed the incident.
- 100% Nursing staff has been educated on the signs and symptoms of hypoglycemia and hyperglycemia by DON and RN, ADON.
- Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
- NP was notified of the change in condition and MD notified of the resident being hypoglycemia and being sent to ER.
- V6 and V27 educated on ensuring right medication and dose prior to medication administration by DON.
- The monthly refresher will begin at our all-staff meeting.
- All nursing staff educated on the 5R's of medication administration by DON.
- V6 and V27 were educated and completed competent in medication administration on Narcan, Epinephrine, and Baqsiumi.
- 100% of nursing staff was educated on medication administration.
- DON or Designees will audit medication administration 2 times a week for 3 months.
- DON or Designee will audit 3 residents 2 times weekly to ensure blood sugar are within normal limit per MD orders for 3 months.
- DON or designee will perform an audit to ensure all emergency was handled correctly. This will be ongoing for 3 months and reviewed in our QA meeting.
- The emergency kits and the cart will be audit weekly to ensure educational material is in place. This will be ongoing for 3 months and review in our QA meeting. This will be monitored by ADON or designee.
- ADHOC QA completed with IDT regarding Policy and procedure.
- QA to review policy and procedure as part of Quality Assurance Process.
- This will be ongoing for 3 months.