Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
Facility staff failed to follow physician orders for medication administration for four residents, resulting in multiple medication errors. In one instance, a registered nurse administered methadone 5 mg to a resident with chronic pain and multiple comorbidities, despite a physician order for 2.5 mg. The error occurred on the day the dosage was changed, and the nurse reportedly pulled the wrong medication supply card. The resident was assessed after the error, with no changes in condition noted. Another resident with osteomyelitis and severe cognitive impairment received intravenous ertapenem at the wrong time. The LPN administered the antibiotic six hours earlier than scheduled, after confusing it with another IV antibiotic. The error was documented, and the resident was monitored, with no new care orders issued in response. Additionally, a resident with multiple chronic conditions received another resident's medications, including a cancer medication, during an evening medication pass. The incident was reported, and the resident was monitored, with no acute distress or changes in condition observed. In a separate incident, a resident with Alzheimer's disease and other significant health issues was given Percocet 10-325 mg instead of the prescribed oxycodone 2.5 mg for pain management. The error occurred when a new nurse pulled the incorrect medication supply card. The resident was assessed and remained at baseline, with no changes in condition following the error. In all cases, the errors were documented, and the responsible staff members were no longer employed at the facility at the time of the survey.