Failure to Administer Prescribed Gabapentin Dose Due to Medication Aide Error
Penalty
Summary
A deficiency occurred when a resident with a history of a Type II Dens fracture, elevated white blood cell count, cervicalgia, pain, and adult failure to thrive did not receive her prescribed dose of Gabapentin as ordered by the physician. The resident was supposed to receive 600 mg of Gabapentin in the evening for pain management, but was only administered 300 mg on two consecutive evenings by a medication aide (MA B). The medication aide noticed two separate orders for Gabapentin—one for 300 mg three times daily and another for 300 mg twice daily—but chose to administer only one 300 mg capsule in the evening, believing the combined dose was too high and suspecting an entry error. The aide did not consult with a nurse for clarification, as required by facility policy. Record reviews confirmed that the resident's medication administration record (MAR) reflected the administration of only 300 mg Gabapentin in the evening, rather than the ordered 600 mg. Interviews with the medication aides revealed that while one aide (MA A) followed the orders as written, the other (MA B) made an independent decision to alter the prescribed dose without seeking clarification from nursing staff. The nurse practitioner (NP) who wrote the orders confirmed that the intent was for the resident to receive 600 mg in the morning and evening, and that the two separate orders were due to system requirements for MAR documentation. The NP was not contacted by staff regarding any confusion about the orders. The facility's policy on medication errors defines a medication error as any administration not in accordance with physician's orders, and specifically includes wrong dose as an example. The director of nursing (DON) confirmed that staff are expected to follow orders as documented and to seek clarification if there is any confusion. The failure to administer the correct dose as ordered was identified as a significant medication error, with the potential for increased pain for the resident.