Significant Medication Errors Due to Nurse Actions and Documentation Failures
Penalty
Summary
Two residents experienced significant medication errors due to the actions and inactions of a registered nurse. One resident, with diagnoses including generalized anxiety disorder, dementia with behavioral disturbance, and major depressive disorder, was prescribed clonazepam for anxiety. The registered nurse documented administering the medication, but there was no evidence in the controlled substance drug log or blister pack that the medication was actually given, as the tablet count remained unchanged from the previous day. Another resident, who had osteomyelitis of the left hand and a partial finger amputation, was ordered to receive intravenous ceftriaxone daily. The medication administration record showed multiple missed doses on specific dates, with no documentation explaining the omissions. The registered nurse responsible for these administrations could not account for the extra antibiotic bags found in the medication room, which matched the number of unsigned doses, and was unable to provide a satisfactory explanation during interviews. Interviews with facility staff confirmed that only registered nurses were permitted to administer intravenous antibiotics, and that any missed doses should be reported and documented. The physician was not notified of the missed antibiotic doses, and there was no documentation in the medical record regarding the omissions. The facility's policy required all medication errors to be reported and investigated, but there was a lack of evidence that this process was followed in these cases.