Failure to Ensure Accurate Labeling and Administration of IV Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate labeling and administration of intravenous medication for a resident. On the specified date, a nurse administered an IV antibiotic, Meropenem, to a resident without verifying that the medication bag was correctly labeled with the resident's name. The nurse noticed only the medication name and dosage, but did not check the label for the resident's name, and was alerted to the issue by a family member who pointed out that the name on the medication bag was different. The medication had already been infused for less than five minutes before the error was discovered. The resident involved had multiple diagnoses, including atrial fibrillation, coronary artery disease, hypertension, wound infection, diabetes mellitus, and non-Alzheimer's dementia, and was assessed as having severe cognitive impairment. The physician's order for Meropenem IV was clearly documented, specifying the dosage and duration for treatment of a sacral wound infection. Despite these orders, the medication administration process was not followed as required, specifically the verification of the resident's identity prior to administration. The facility's medication administration policy required staff to verify the medication label against the medication sheet for accuracy, including the resident's name, drug, frequency, duration, strength, and route. However, this procedure was not followed in this instance, resulting in the administration of medication from a bag not labeled with the correct resident's name. The incident was reported by both the nurse and the family member, and documentation confirmed that the error was due to failure to adhere to established medication administration protocols.