Failure to Notify Resident and Physician of Medication Error
Penalty
Summary
The facility failed to notify both the resident and the resident's primary care physician of a medication error involving the administration of pain medication. The resident, who had multiple diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, asthma, hypertension, chronic kidney disease, polyneuropathy, severe morbid obesity, osteoarthritis, and obstructive sleep apnea, was prescribed Oxycodone ER 10 mg every 12 hours for moderate to severe pain and Oxycodone 5 mg every 12 hours as needed for pain rated five to ten. On a specific date, the nurse documented administering the scheduled Oxycodone 10 mg dose but did not document administration of the as-needed 5 mg dose. However, controlled drug records indicated that the resident received the 5 mg dose instead of the prescribed 10 mg dose at that time. During a shift change narcotic count, it was discovered that the nurse had administered the incorrect dose of Oxycodone. There was no documented evidence in the medical record that either the resident or the resident's physician was notified of this medication error. Facility policy required prompt notification of the resident, physician, and resident representative of changes in the resident's medical condition or status, but this was not followed in this instance.