Unordered Medications Administered Due to EMAR and Identification Errors
Penalty
Summary
The facility failed to ensure that a resident received only medications ordered by a physician, resulting in the administration of two medications that were not prescribed for that resident. The resident had been admitted with diagnoses including hypo-osmolality and hyponatremia, acute skin changes due to ultraviolet radiation, dysphagia, difficulty walking, and an unspecified malignant neoplasm of the skin of the left lower limb, including the hip. Review of the order summary showed no orders for Duloxetine 30 mg or Omeprazole 20 mg, and the resident’s diagnoses and Minimum Data Set contained no indications of depression, anxiety, GERD, or other psychiatric or mood disorders that would support those medications. Despite this, the resident received Omeprazole 20 mg and Duloxetine 30 mg, which were not ordered for them. According to staff interviews and documentation, an agency nurse had been in the middle of a medication pass when the facility decided to send the agency nurse home and replace them with a staff RN. The agency nurse, reportedly upset about being sent home, did not provide a full report, leaving the RN to determine where the medication pass had been left off. The RN was informed that the resident had not received their medications and proceeded to administer morning medications, but did so using the wrong electronic medication administration record. The RN did not verify the correct resident EMAR before administration and did not observe the resident taking the medications. After administering the medications, the RN realized the error upon reviewing the EMAR, then called out to the resident to stop taking them, but the resident had already ingested Omeprazole and Duloxetine. The facility’s medication administration policy required adherence to the 10 rights of medication administration and verification of resident identity by verbal confirmation and visual checks of name and photo, or alternative methods if no photo was available.
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