Significant Medication Administration Errors Involving Two Residents
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration by facility staff. One resident, admitted with diagnoses including nontraumatic intracerebral hemorrhage, diabetes mellitus type 2, and glaucoma, had a physician's order for a Bisacodyl rectal suppository to be administered rectally every 12 hours as needed for constipation. However, the suppository was inserted into the vagina instead of the rectum, as confirmed by the resident and documented in the change of condition form. The Director of Nursing acknowledged that this constituted a medication error and noted the potential for delayed treatment and pain. Another resident, admitted with cellulitis of the lower extremity, malignant neoplasm of the bladder, and heart failure, was prescribed a 14-day course of Ertapenem Sodium Injection Solution to be administered intravenously each morning for cellulitis. Review of the Medication Administration Record revealed that on two occasions, there were no staff initials to indicate that the antibiotic was administered as ordered. The Infection Preventionist confirmed the importance of completing the full course of antibiotics and acknowledged that the missed doses represented a failure to follow the physician's order. Facility policies reviewed indicated that medications must be administered in accordance with prescriber orders and professional standards, and specifically addressed the importance of correct route and completion of medication administration. The observed failures in both cases were not in accordance with these policies, resulting in significant medication errors for both residents.