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Compliance Inspector (CI) Heather Radney conducted an investigation of the allegation that on 5/16/23, a teacher gave a steroid medicine to the wrong child. The allegation is substantiated based on the following information:
5 CSR 25-500.192(3)(B) which states "All medication shall be given to a child only with the dated, written permission of the parent(s) stating the length of time medication may be given."
On May 17, 2023, Director Stephanie Shockley reported to the Office of Childhood that Child B had received medication by accident that was not his. On May 23, 2023, CI Radney conducted a telephone interview Stephanie, who reported that Caregiver Krystal O'Donoghue went to give Child A his medication but gave it to Child B instead. Krystal contacted her immediately and they called Poison Control and Parent B. Since the incident, they have looked up who has taken training on medication administration and have conducted a medication administration review. They have a new procedure for medication administration, including two people present and signing off on medication and being handled in the office rather than the classroom.
On May 23, 2023, CI Radney received and reviewed statements from caregivers and the medication authorization form and incident report. Caregiver Jennifer Dennison's statement reads "Today, 5/16/23, Mrs. Stephanie and Mrs. Krystal came to me and said that Krystal had accidentally given [Child B] a dose of another child's medication. I obtained the name of the medication, the dose and time it was given, along with [Child B]'s age and weight then I called the poison control hotline. I have all of that information to the representative on the phone and she said that there should be no reason to be concerned at all. That the medication is a steroid and should not cause any reaction. She stated that it is possible he might be hungry or a little tired but that is all. She stated that she would call back in one hour to touch base but there was no reason to worry at this time. When she called back to check in [Child B] had already been picked up by his parent so I made sure that she had the contact information for her, signed Jennifer Dennison and dated 5/16/23. Caregiver Aleah Shultz' statement reads "5/16/23 While Krystal was administering [Child A]'s medicine at one table, I was at the other with a group of kids. Krystal was talking to both [Child A] and [Child B], I heard her say "Here is your medicine [Child A]" as she had the syringe of medicine. Then I saw [Child B] open his mouth and Krystal put it in. I said "Krystal" and as soon as I did she said "Oh my God I just gave [Child B] [Child A]'s medicine." She then went out to tell Stephanie, I went to [Child A] and Shyla went to the other table. Krystal poked her head back in and asked Shyla to please give [Child A] his medicine and Shyla did." signed Aleah Shultz. The Medication Authorization form identifies the medication as Hydrocortisone Tablet 5mg take 1.25 3x daily to be given to Child A. There was no Medication Authorization form giving permission to give Child B the medication. The Incident Report reads date of injury/incident as 5/16/2023 2:00 p.m., in the classroom. Child B was given another child's medication Hydrocort 1.25 ml which is a steroid by accident. While the teacher was administering the meds she was talking to both students and gave the meds to the wrong one (Child B). Poison Control was called. Parent B was called. Poison Control stated that there was no concern with this medication, that the most that may happen is him being more thirsty or hungry. Poison Control did state they would call back in an hour to check on him. Krystal O'Donogue and Jennifer Dennison called poison control but was told no first aid needed to be administered. Updated medication administration training done as well as taking children out of the classroom away from all distractions while administering medication, Signed by Stephanie Shockley and Parent B.
On July 11, 2023, Caregiver Krystal O'Donoghue reported the kids were at the table, getting ready for snack. Child A and Child B were sitting next to each other. She was talking to one child, and she turned to talk to another teacher. She looked back at the children at the table. She said "Open your mouth" to Child A and Child B opened his mouth, and she gave him the medicine. She realized immediately it was the wrong child. Aleah and Shyla were both in the room with her when it happened. Aleah said "What just happened?" and she said "OMG I just gave the wrong child the medicine." She immediately went to the hallway and called for Stephanie. Stephanie walked out of her office and toward her. She told Stephanie what happened. Stephanie and another teacher went in to the classroom and took Child B. She was really upset with herself and concerned for Child B, so she went with Jennifer Dennison into the office to call Poison Control. Poison Control said they did not expect to see any side effects at all from the medication and if they did, it would be that Child B is extra tired or hungry. Poison Control said they did not have concerns beyond that. Stephanie contacted Parent B while they were on the phone with Poison Control. Parent B called her pediatrician who told her to call Poison Control. When Parent B arrived to pick him up, she said Poison Control had told her the same thing they'd told them. Parent B took Child B home to observe him at home and she messaged her back a few hours later saying he was fine. Poison Control contacted Parent B about an hour later and she told them he was acting fine. Now they take the child out of the room and into the office with another adult to verify the child, medication and dosage.
On July 11, 2023, CI Radney interviewed Parent B. She reported that Stephanie Shockley called her immediately after the incident and told her that Krystal had given Child B medication that wasn't his. Stephanie advised her to call his doctor, who told her to call Poison Control, which she did. Poison Control said the medication wouldn't hurt him but could make him tired and thirsty. When she went to get him from daycare, Krystal was in the office crying. She told her he was fine and that she isn't mad. She feels like they handled the incident appropriately.
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