Medication Administration Errors Result in Resident Harm
Penalty
Summary
The facility failed to prevent significant medication errors for three residents, resulting in harm to two of them. Resident 9, who has moderate cognitive impairment, did not receive their prescribed Methadone and Lyrica at the scheduled times on December 28, 2024, leading to a day of unmanaged pain. The medication administration audit confirmed that Methadone was administered at 4:50 PM and Lyrica at 4:51 PM, despite being scheduled for the morning. Resident 9 filed a grievance stating they had to request their routine morning pain medications and experienced pain throughout the day. Resident 10, diagnosed with epilepsy and hypertension, did not receive their prescribed Phenobarbital on the same day, although it was signed off as administered on the Medication Administration Record. The controlled drug record count sheet confirmed the medication was not given. Resident 14, with intact cognition and diagnosed with hypertension and chronic pain, requested Tramadol for pain at noon and again two hours later, but only received it at 4:05 PM after a third request. The delay in administering pain medication led Resident 14 to consider going to the hospital due to severe pain. The Director of Nursing acknowledged that pain medication should be administered timely.
Plan Of Correction
Residents 9, 10 and 14 were assessed and no adverse reactions, therefore no further adjustments to treatment was required per CRNP. The nurse involved has since been terminated. No other like residents identified. A comprehensive medication administration review of current residents will be completed to ensure that medications were completed and signed off as ordered. Director of nursing / Designee will educate licensed staff on F tag 0760 residents are free of significant med errors, focusing on ensuring medications are administered as prescribed. Audits of 5 random medication administration will be completed by unit managers /designee per week for 4 weeks to ensure pain medications are administered as prescribed. Results of the audits will be reviewed by the QAPI committee for recommendations.