Medication Administered Without Physician Order
Penalty
Summary
A registered nurse (RN) administered Ceftriaxone, an antibiotic, intramuscularly to a resident without obtaining a physician's order. The resident had been admitted with diagnoses including anxiety, unspecified psychosis, urinary tract infection (UTI), and nausea. Laboratory results indicated a possible UTI, but further testing was required to determine the appropriate antibiotic. Despite this, the RN wrote and signed an order for Ceftriaxone and administered the medication from the emergency kit, without consulting or receiving authorization from the resident's physician. The medication administration record and nursing progress notes confirmed that the RN acted independently, and the physician later confirmed that no order had been given for the antibiotic. The resident in question had moderate cognitive impairment and required moderate assistance with activities of daily living. The incident was discovered when the Director of Nursing (DON) reviewed the order and found discrepancies, leading to confirmation that the physician had not been contacted. The facility's policy clearly states that no medication should be administered without a written physician's order. The RN admitted to administering the medication based on her own judgment, citing the resident's previous history with Ceftriaxone and the timing of the lab results.