Improper Medication Administration Leads to Accidental Ingestion of Dakin's Solution
Penalty
Summary
A deficiency occurred when a licensed nurse prepared medication for a resident and handed it to another licensed nurse for administration, resulting in a breakdown of safe medication administration practices. Specifically, a resident with multiple diagnoses, including osteomyelitis, was admitted to the facility and required pain management with Morphine Sulfate ER. On the day of the incident, a nurse brought a cup containing a clear liquid, which was on top of the treatment cart, to the resident along with pain medication. The resident ingested the liquid and immediately reported that it tasted like bleach. Further review revealed that the clear liquid was Dakin's solution, a diluted bleach solution intended for wound cleansing, not for oral consumption. The progress notes indicated that the solution had been poured for wound treatment, but due to miscommunication and improper handoff, another nurse mistakenly gave it to the resident as water. The facility's policy required that medications be administered safely and by the individual who prepared them, with proper documentation, which was not followed in this instance.