Improper Storage and Administration of Medications Resulting in Potential Medication Error
Penalty
Summary
A deficiency occurred when a nurse failed to properly store and dispose of medications for a resident with Alzheimer's disease and type 2 diabetes. The nurse prepared the resident's evening medications but, upon discovering the resident was not present, placed the medications in the top drawer of the medication cart instead of discarding them as required by facility policy. Another medication cup for a different resident was also present in the same drawer, creating confusion about which medications were administered. Subsequently, the nurse administered the previously prepared medications to the resident when he returned, after which the resident became unresponsive and required hospital transfer for a possible medication overdose. Facility staff and emergency medical services were unable to confirm whether the resident had received the correct medications or another resident's medications, as the nurse could not verify what had been administered. The nurse acknowledged that he was overwhelmed and did not follow proper medication administration protocols, including not preparing medications for more than one resident at a time and not discarding unused medications. Interviews with facility leadership confirmed that the nurse's actions were not in accordance with the rights of medication administration and the facility's medication management policy. The policy specifically states that medications unable to be administered after preparation must be discarded, and that medications should not be pre-set for more than one resident at a time. The failure to follow these procedures resulted in the potential compromise of medication safety for the resident involved.