Failure to Administer Gabapentin as Ordered Due to Medication Aide Error
Penalty
Summary
A seventy-six year old woman with a history of a Type II Dens fracture, elevated white blood cell count, cervicalgia, pain, and adult failure to thrive was admitted to the facility and had a care plan focused on pain management. Physician orders specified that she was to receive Gabapentin 300 mg three times daily and an additional 300 mg twice daily, totaling five doses per day. Medication administration records and staff interviews revealed that, over several days, the resident did not receive the full prescribed evening dose of Gabapentin. Instead, a medication aide (MA B) administered only 300 mg in the evening, rather than the ordered 600 mg, due to her belief that the orders were duplicative or erroneous. MA B did not consult with a nurse for clarification, as required by facility policy, and marked the medication as given on both orders despite only administering one dose. The medication aide (MA A) who worked the morning shift followed the orders as written and administered the prescribed doses, but also noted the presence of two separate Gabapentin orders in the system. MA A stated that she would consult a nurse if she suspected a discrepancy, but did not perceive an issue in this case. The medication count revealed missing capsules consistent with the number of doses that should have been administered, confirming that not all prescribed doses were given. The nurse practitioner who wrote the orders confirmed that the intent was for the resident to receive 600 mg in the morning and 600 mg in the evening, and that the two orders were entered separately due to system requirements. She was not contacted by staff regarding any confusion about the orders. The facility's policy requires that medication aides administer medications as ordered and consult with a nurse if there is any confusion or suspected error. The Director of Nursing confirmed that staff are expected to follow orders as written and seek clarification when needed. The failure to administer the correct dose of Gabapentin as ordered constituted a significant medication error, as defined by facility policy, and was not reported or clarified by the staff involved.