Medication Error: Unprescribed Oral Administration of Amiodarone and Vitamin B12
Penalty
Summary
A deficiency occurred when a certified medication assistant (CMA) administered Amiodarone, a heart medication, and Vitamin B12 to a resident who was not prescribed these medications. The resident, who had a history of stroke, dysphagia, and required a PEG tube for all nutrition and medication administration, was given the medications orally, contrary to physician orders and the resident's care plan. The resident reported that the nurse insisted he take the pills by mouth, despite his objections and the established protocol for PEG tube administration. Record reviews confirmed that the resident did not have active orders for Amiodarone or Vitamin B12, and that all medications were to be administered via the PEG tube due to unsafe swallowing. Interviews with staff, including the nurse practitioner, LVNs, and the DON, corroborated that the CMA failed to verify the medication orders and did not follow the required procedures for medication administration. The facility's policy and staff training emphasized the necessity of verifying physician orders, following the seven rights of medication administration, and ensuring medications are given by the correct route. The incident was identified after the resident reported receiving the wrong medications, prompting staff to review the medication administration records and care plan. The CMA involved was placed on investigatory suspension, and staff interviews confirmed that the error resulted from not checking the MAR and care plan prior to administration. The facility's documentation and staff statements indicated that the error was preventable and occurred due to failure to adhere to established medication administration protocols.