Medication Administration Error: Incorrect Frequency of Iron Supplement
Penalty
Summary
The facility failed to prevent a significant medication error by administering a resident's ferrous sulfate (iron supplement) at an incorrect frequency for 82 days. The physician's order, as documented in both the hospital discharge summary and the facility's physician order sheet, specified that the resident should receive ferrous sulfate once weekly on Fridays, in conjunction with vitamin C. However, review of the electronic Medication Administration Record (eMAR) showed that staff administered the ferrous sulfate daily instead of weekly, while the vitamin C was given as ordered on Fridays. The error originated from the process of entering physician orders into the facility's system. The charge nurse was responsible for inputting the orders into the Physician Order Sheet (POS), which then automatically populated the eMAR. Both Certified Medication Technicians (CMTs) and the Director of Nursing (DON) confirmed that the eMAR displayed the ordered frequency, but this information was not prominently visible on the administration screen. As a result, staff did not notice the discrepancy between the ordered and administered frequency, and the medication was given daily without interruption. Interviews with staff revealed that the process for identifying and clarifying order discrepancies was not effectively followed. CMTs stated they should notify the charge nurse or DON if they noticed any discrepancies, but in this case, the daily administration of ferrous sulfate continued unchecked. The DON and Administrator acknowledged that the frequency information was not easily noticeable on the eMAR, contributing to the prolonged error. The resident involved had multiple complex diagnoses, including atrial fibrillation, severe protein-calorie malnutrition, and emphysema, and was at risk for inadequate nutrition and ineffective breathing patterns.