Medication Administration Error Due to Failure to Follow Physician's Orders
Penalty
Summary
A deficiency occurred when a nurse failed to administer medication according to professional standards and physician's orders for one resident. The facility's policy required staff to verify the correct medication, dose, time, and route before administration. Despite this, an LPN administered 400 mg of gabapentin in the morning instead of the prescribed 300 mg dose for that time. The error was identified when the LPN reviewed the physician's order after the medication had already been given. The resident involved had a history of inflammatory neuropathy, anemia, and hypertension, and was admitted with orders for both 300 mg and 400 mg gabapentin at different times of day. This incident was observed during a medication pass and confirmed through policy review and staff interview, demonstrating a failure to follow established medication administration protocols.