Medication Administered Without Active Physician Order
Penalty
Summary
A significant medication error occurred when a Licensed Practical Nurse (LPN) administered 5 mg of oxycodone to a resident who did not have an active physician order for the medication. The resident, who had diagnoses including encephalopathy, epilepsy, asthma, anxiety, dysphagia, and muscle weakness, was noted to have severely impaired cognition and required assistance with self-care. The administration of oxycodone was prompted by the resident exhibiting signs of agitation. The medication was documented on the Controlled Drug Record log but was not recorded on the medication administration record due to the absence of an active order. Review of facility policy confirmed that medications are to be administered only in accordance with written physician orders and all administrations should be recorded in the medication administration record. The incident was verified by the facility administrator, who confirmed the LPN's actions as described in the incident report.