Failure to Supervise Student Nurse Results in Significant Medication Error
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to provide direct supervision to a student nurse (SN) during a scheduled medication pass, resulting in a significant medication error. The LVN prepared medications at the medication cart and handed them to the student nurse, instructing the student to administer them to a resident identified only by bed assignment. The LVN did not accompany the student nurse to the resident's bedside or verify the resident's identity, and the student nurse administered the medications without confirming the resident's name or identity. As a result, the resident received another resident's medications, including Valsartan, multivitamin and minerals, Guaifenesin ER, Eliquis, Carvedilol, Keppra, and Magnesium Oxide, instead of their prescribed medications such as Glipizide, Metformin, Baclofen, vitamin D, Iron, Finasteride, and Lacosamide. The resident involved had a history of hemiplegia, hemiparesis, atrial fibrillation, and type 2 diabetes, and was assessed as having moderate cognitive impairment. Following the medication error, the resident became unusually sleepy, had low blood pressure, and was unable to recall events from the day. The resident's responsible party noticed the change in condition and requested a blood pressure check, which revealed hypotension. The Director of Nursing (DON) was notified and assessed the resident, who was then transferred to a general acute care hospital for evaluation, where blood tests and radiological studies were performed to rule out adverse drug effects. Interviews with the student nurse, another student nurse, the LVN, and the DON confirmed that the LVN routinely failed to provide direct supervision during medication administration by student nurses and referred to residents by bed assignment rather than by name. The facility's policy required verification of resident identity and direct supervision of student nurses during medication administration, which was not followed. The failure to adhere to these protocols led to the resident receiving the wrong medications and being exposed to unnecessary medical interventions.