Failure to Prevent Significant Medication Errors and Late Pain Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to prevent significant medication errors for two residents. For one resident with end stage renal disease, diabetes, and osteomyelitis, the physician ordered Cubicin 700 mg IV every other day for 34 days to treat an abdominal abscess. On one occasion, staff administered Cubicin 500 mg IV that was intended for another resident, resulting in the resident not receiving the full prescribed dose. The DON reported that the nurse recognized the error only after the IV bag had been completely administered and she saw the other resident’s name on the bag. The resident later confirmed being informed by the facility that a medication error had occurred and that she had not received the full dose of Cubicin. The facility’s medication administration policy required licensed nurses to identify the resident by photo in the MAR and compare the medication source with the MAR to verify resident name, medication name, form, dose, route, and time of administration. The second resident, admitted with acute and chronic respiratory failure, polyneuropathy, and anxiety disorder, had a physician’s order for routine oxycodone 10 mg every four hours for pain at specified times throughout the day and night. Review of the MAR showed that the 8:00 A.M. dose of oxycodone was administered at 11:18 A.M. on one date. During observed medication administration on another date, an LPN gave the resident’s 8:00 A.M. oxycodone dose at 10:05 A.M. The LPN confirmed that the medication was late and acknowledged that medications were supposed to be administered within one hour before or after the scheduled time. A regional RN also confirmed that the resident’s oxycodone doses had been administered late on both dates. The facility’s medication administration policy specified that medications should be administered within 60 minutes prior to or after the scheduled time.
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