Medication Borrowing Results in Failure to Meet Professional Standards
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards and facility policy, resulting in a medication ordered for one resident being administered to another. Specifically, a registered nurse withdrew two oxycodone 5 mg tablets from one resident's medication supply and administered them to a different resident, despite each resident having distinct physician orders for their pain medication. This action was taken after the nurse consulted with the facility administrator, who approved the borrowing of medication, even though the facility's policy explicitly prohibits administering medications ordered for one resident to another unless permitted by state law and approved by the director of nursing services. The incident involved two residents with significant medical histories. One resident had diagnoses including pain in the left knee and hip, diabetes, and cognitive communication deficit, and had an order for oxycodone 5 mg to be given as needed. The other resident, who received the borrowed medication, had diagnoses such as spinal stenosis, muscle weakness, chronic embolism, and severe pain at the time of administration, with a physician's order for oxycodone 10 mg as needed. The medication administration records and controlled drug use records confirmed that the medication was not administered as prescribed and that the nurse documented the borrowing of medication in the records. Interviews with the nurse and facility leadership revealed that the nurse acted under the direction of the administrator, who was attempting to address a situation involving a resident in severe pain and a dissatisfied family. The nurse acknowledged that she did not initially consider the action a medication error, as she believed she was resolving an urgent issue, but later recognized it as such. The director of nursing was not present at the facility during the incident and was informed after the fact.