Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
Facility staff failed to follow professional standards of practice for medication administration for a resident with multiple complex diagnoses, including multiple sclerosis, epilepsy, chronic pain, and severe cognitive impairment. The staff did not compare the medication label to the physician's order before administering morphine sulfate, resulting in the resident receiving multiple incorrect doses. The medication administration record (MAR), narcotic control sheet, and the actual medication bottle from the pharmacy contained discrepancies in concentration and dosing instructions, which were not identified by the nursing staff prior to administration. The pharmacy provided a morphine sulfate solution with a different concentration than what was ordered, and the label on the medication bottle instructed a dosage that did not match the physician's order. Nurses administered the medication according to the incorrect label and did not verify the concentration or instructions against the original physician's order, as required by facility policy. The facility's policy clearly stated that staff must check the label to verify the right medication, dosage, time, and route before administration, but this procedure was not followed in this instance. The deficiency was identified through staff interviews, clinical record review, and facility policy review. The administrator confirmed that the error occurred due to both the pharmacy's failure to notify the facility of the concentration change and the nursing staff's failure to adhere to established medication administration protocols. The incident involved the administration of morphine sulfate in incorrect doses to a resident who was severely cognitively impaired and receiving end-of-life care.