Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. Resident R69, who had a medical history including heart failure, atrial fibrillation, and hypertension, was prescribed Coumadin with two different dosages on separate orders. On November 6, 2024, a charge nurse administered both a 5mg and a 6mg tablet of Coumadin to the resident, totaling 11mg, due to confusion over the orders. This error occurred because the nurse noticed two different orders for Coumadin on the medication administration record (MAR) and administered both doses, despite the potential for major or fatal bleeding associated with Coumadin, as highlighted in the manufacturer's warning. Resident R64, diagnosed with type 2 diabetes, arthritis, and low back pain, experienced a medication error when the nurse administered Metformin instead of Gabapentin. On July 14, 2024, the resident was given the wrong medication but spit it out and refused to take it. Despite this, the resident was upset and requested a supervisor. On August 12, 2024, the resident again received Metformin instead of Gabapentin, but did not swallow the pill and spit it out. The resident was stable but required hospitalization following the incident.
Plan Of Correction
The facility immediately assessed resident R69 after administering the incorrect dosage of Coumadin. The facility immediately contacted the medical provider, and a PT/INR was ordered. The facility continued to monitor resident R69 for bleeding or bruising. The facility followed all subsequent MD orders. The facility immediately assessed resident R64 after administering the wrong medication on 7/14/2024. The medical provider was notified. Resident R64 did not require any further intervention, as per MD. The facility immediately interviewed LPN that administered incorrect medication and issued a written education to the LPN. The facility immediately assessed resident R64 after administering the Metformin medication 90 minutes prior to the scheduled time on 8/12/2024. The medical provider was notified. Resident R64 "spit out the medication and" did not require any further intervention as per MD. The facility immediately interviewed the LPN and took appropriate disciplinary action. The facility immediately initiated education to licensed nurses on medication administration and documentation in resident's electronic health record. All residents have the potential to be affected by the deficient practice. The facility will educate all licensed nurses on medication administration and documentation in resident's electronic medical record. The facility will utilize medication administration record documentation audit tool. Director of Nursing / designee will complete random audits of 5 resident MAR weekly x4 weeks, then monthly x2 months. Findings will be reported to the QAPI committee.