Immediate Jeopardy Due to Medication Administration Error and Failure to Follow Policy
Penalty
Summary
A significant medication administration error occurred when a nurse pre-prepared and stacked multiple residents' medications, resulting in one resident receiving another resident's medications. The nurse failed to follow the facility's medication administration policy, which requires verification of the six rights of medication administration and prohibits pre-popping and stacking medications. The error was not immediately reported by the nurse involved, and the resident was subsequently given their own scheduled medications as well. The affected resident, who had a complex medical history including hemiplegia, bradycardia, Parkinson's disease, and other serious conditions, was found to be lethargic, hard to arouse, and had a heart rate in the 40s after receiving the wrong medications. The error was discovered when another resident reported to a different nurse that he had witnessed his medications being given to the wrong person. Upon assessment, the resident was sent to the emergency room, where he required critical care, including intubation, due to medication overdose and associated complications. Further investigation revealed that the practice of pre-preparing and stacking medication cups was ongoing, as observed by surveyors during their visit. Staff involved in medication administration confirmed that medications, including controlled substances, were being pre-popped and stacked in advance, contrary to facility policy. The incident was not promptly reported to supervisory staff or the physician as required by the facility's medication error policy.
Removal Plan
- R4 was sent to the emergency room for treatment and remained in the hospital.
- V3's employment with the facility was terminated and the incident reported to the State Nursing Board.
- An emergency Quality Assurance Performance Improvement (QAPI) meeting was held to review and interpret all audit findings, review all procedures, review investigation, review root cause analysis, and review all facts surrounding the incident. Findings will be reported at the monthly QAA meeting for a minimum of 3 months. All applicable facility policies and procedures for medication administration were reviewed/revised by the QAPI team.
- V11/Assistant Director of Nursing re-educated licensed nurses on facility policies regarding Medication Administration as well as medication errors and medication administration reconciliation guidelines. All nurses were educated prior to working their next shift including agency nurses. Sign-in sheets were utilized.
- An audit of all med carts to ensure no other medications were opened in advance of administering to residents was completed by V11 and continued.
- The facility's contracted pharmacy service performed a med cart audit and medication administration audit.
- The DON or designee will audit med carts on all shifts to ensure medications are being prepped and administered accordingly weekly for 4 weeks then bi-weekly for 2 months. The audits will continue until compliance can be maintained for 3 consecutive months.
- The DON or designee will educate all new hire licensed nurses on medication administration and reconciliation guidelines.
- Education on Medication Administration and Medication Error sign in sheets and course material reviewed with no concerns.
- Medication Cart Audit was completed by and observed by the State Agency V12, V13, and V14's med carts. No concerns.