Significant Medication Error and Lack of Documentation After Wrong Drug Administered
Penalty
Summary
Facility staff failed to ensure residents remained free from significant medication errors when a Certified Medication Technician (CMT) administered one resident’s prescribed medication to another resident. The facility’s Administering Medications policy, revised April 2019, required staff to verify resident identity using methods such as checking identification bands, photographs, and, if necessary, confirming identity with other personnel, and to check the medication label three times to ensure the right resident, medication, dose, time, and route. Despite these requirements, CMT A reported giving one resident another resident’s Oxycodone instead of the ordered Ativan. The resident’s physician order sheet did not contain any order for Oxycodone, and the resident was assessed as cognitively intact with diagnoses of anxiety and depression. The resident reported receiving two small white pills from CMT A, then feeling “really funny,” and later being informed by a nurse that 10 mg of Oxycodone had been given instead of Ativan. The facility’s policy also required that medication errors be documented, reported, and reviewed by the QUAPI committee, and that such errors be documented in the resident’s chart with details of what happened, when it happened, corrective actions taken, and when the family and physician were notified, as well as monitoring and documentation of adverse reactions. However, review of the resident’s progress notes and facility-provided records for the date of the incident showed no documentation of a medication error or any facility investigation related to the error. The administrator stated there had been one medication error for this resident but did not know the details due to being on leave and acknowledged there was no proof of what the prior management nurse had done regarding the investigation. The resident reported that staff called the physician and monitored blood pressure after the error and that CMT A apologized, but the lack of corresponding documentation and investigation records demonstrated the facility’s failure to follow its own medication administration and error-reporting policies.
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