Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, as evidenced by an incident involving a resident, referred to as Resident R3. Upon admission, Resident R3's medications were incorrectly entered into the system by the Assistant Director of Nursing (ADON), resulting in the administration of medications intended for another resident. Specifically, Resident R3 was given gabapentin and melatonin, which were not prescribed for them, while their prescribed medications, including aspirin, Eliquis, atorvastatin, metoprolol tartrate, mirtazapine, and senna, were not administered. This error was discovered after Resident R3 experienced a medical emergency and was transferred to the hospital, where the discrepancy in medication records was identified. Resident R3 had a medical history that included COVID-19, pneumonitis, hypothyroidism, and hypertension. Upon admission to the hospital, Resident R3 was found to have shortness of breath, respiratory acidosis, and pleural effusion, and was diagnosed with sepsis due to COVID-19. The facility's Director of Nursing confirmed the medication error, and the ADON acknowledged responsibility for the mistake. The resident's family was informed, and it was noted that Resident R3 did not have a history of allergies to the medications they were incorrectly given.
Plan Of Correction
Resident R3 no longer resides in the facility. Resident R4's medications were reconciled by the Director of Nursing and noted with correctly prescribed medications. The attending physician reviewed the medications and validated accurate transcription. Current residents have the potential to be affected. An audit was completed by the consultant pharmacist with no transcription errors noted. The nurse who made the transcription error was educated by the Director of Nursing on the medication administration policy and the error during one-on-one counselling. Licensed nurses will be educated by the Director of Nursing (or designee) on the medication administration policy. The Director of Nursing will monitor admission orders daily for one (1) month followed by weekly for two (2) months to ensure compliance. Findings will be submitted to the QAPI committee monthly for three (3) months for review. The committee will determine if further audits/actions are required. The Administrator is responsible for ensuring implementation of and ongoing compliance with this plan of correction and addressing and resolving variances as they may occur.