Significant Medication Error Due to Incompetent Medication Administration and Protocol Breaches
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to provide safe nursing and related services, as evidenced by a significant medication error involving a resident. A Certified Medication Technician (CMT) administered a cup of medications intended for another resident, which included multiple drugs such as Schedule II narcotics, anticonvulsants, antidiabetics, and other medications. This error occurred after the CMT became distracted during the medication pass, placed the wrong medication cup in the cart, and subsequently administered it to the wrong resident. The medications had been pre-poured by a Registered Nurse (RN), who also provided the narcotics to the CMT for administration, despite this being outside the CMT's scope of practice. The resident who received the incorrect medications had a medical history including heart failure, intellectual disabilities, and chronic obstructive pulmonary disease. Following administration of the wrong medications, the resident was found lethargic, unresponsive, and with pinpoint pupils. Emergency intervention was required, including the administration of Narcan and transfer to the hospital, where the resident received activated charcoal for overdose treatment. Interviews with staff revealed that the RN had signed out and prepared narcotics for one resident and gave them to the CMT to administer, which was not in accordance with scope-of-practice regulations. The CMT acknowledged being distracted and administering the wrong medications, including narcotics, to the resident. The Director of Nursing confirmed that the RN should not have delegated the administration of narcotics to the CMT and that medications should not have been pre-poured and left in the medication cart. These failures in following established medication administration protocols and scope-of-practice requirements resulted in a significant medication error and placed the resident in immediate jeopardy.