Incorrect Medication Prepared Due to Misidentification of Ascorbic Acid
Penalty
Summary
The deficiency involves a failure to ensure correct medications were given according to physician orders, resident preferences, and goals for one resident during a medication administration observation. Facility policy on Clinical-Medication Administration required nurses to have a working knowledge of medications, including common dosage, uses, side effects, and the reason for administration, and to observe the rights of medication administration, including the right medicine. Resident #155 had been admitted with diagnoses including a displaced avulsion fracture of the left talus, a pressure ulcer, acute kidney failure, and type 2 diabetes mellitus, and had a Brief Interview of Mental Status score of 15, indicating intact cognition. The physician’s orders included ascorbic acid 500 mg by mouth once daily for wound healing, and there was no order for Saccharomyces boulardii 500 mg. During a medication pass observation, an LPN prepared Saccharomyces boulardii 500 mg and entered the resident’s room intending to administer it, despite there being no order for this medication for the resident. The surveyor intervened before the wrong medication was given, preventing administration. In a subsequent interview, the LPN stated she believed ascorbic acid 500 mg was the same as the probiotic Saccharomyces boulardii 500 mg. When asked for another name for ascorbic acid, the LPN looked it up, identified it as Vitamin C, and acknowledged it was not the same medication, confirming a lack of correct knowledge and verification of the ordered drug prior to administration.
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