Significant Medication Errors Affecting Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, as required by regulation. One resident with Type II diabetes was administered a long-acting insulin injection despite a physician order to hold the medication if the blood glucose level was below 200 mg/dL. At the time of administration, the resident's blood glucose was 109 mg/dL. This error led to the resident experiencing severe hypoglycemia, becoming unresponsive, and requiring emergency intervention with glucagon and close monitoring. In another instance, a resident was given the wrong morning medications by an LPN, including a lower dose of an antihypertensive and an anticoagulant that were not prescribed for them. The error was discovered after administration, and the resident was assessed for adverse effects. The facility's policy requires that medications be administered only as prescribed and that staff verify resident identity and orders prior to administration, which was not followed in this case. A third resident received a diuretic medication at an incorrect frequency due to a transcription error of a hospital discharge order. Instead of receiving the medication two times per week as ordered, the resident was given it two times per day for four days. This error was identified during a review of laboratory results and the original discharge paperwork. In each case, the facility's failure to follow physician orders and established medication administration protocols resulted in significant medication errors affecting three residents.
Plan Of Correction
This Plan of Correction is being prepared and executed because it is required by the provisions of the State and Federal regulations and not because Kingston of Ashland agrees with the allegations and citations listed on the statement of deficiencies. Kingston of Ashland maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Kingston of Ashland's written credible allegations of compliance. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Kingston of Ashland reserves all possible contentions and defenses in any civil or criminal actions or proceedings. Please accept the date of correction 4/17/2025 as the facility's credible allegation of compliance. Resident #111 was treated at the time of the error in the center with no outstanding negative outcomes noted after treatment for low blood sugar. Resident #111 was assessed by nurse at the time of change in condition on 2/17/2024 with blood sugars being checked hourly until blood sugars were within normal range. Resident #111 was assessed by CNP on 2/24/2025. Resident #111 remains in the center. Resident #404's Lasix order was corrected at the time of discovery with no negative outcome noted. Resident #404 was assessed at the time of discovery by nurse on 2/24/2025. Resident #404 was assessed by CNP on 2/25/2025. Resident #404 remains in the center. Resident #302's had no negative outcome related to being administered another resident's medications. Resident #302 was assessed at the time of discovery by the nurse on 3/14/2025. Resident #302 remains in the center. The Director of Nursing or designee will review current residents with orders for insulin to ensure that the medication is being given per order. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will review medication orders for residents that have been admitted since the date of survey exit through the date of compliance to ensure that medication orders were transcribed appropriately upon admission. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will complete medication administration observations on current residents to ensure that medications are given per order. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will educate licensed nurses and certified medication aides on the administering medications policy on or before 4/17/2025. The Director of Nursing or designee will educate licensed nurses on the electronic order entry process and transcription policy on or before 4/17/2025. The Director of Nursing or designee will complete an audit on 5 residents weekly for 4 weeks that receive insulin to ensure medication was given per order. The Director of Nursing or designee will complete medication order audits on 5 new admissions weekly for 4 weeks to ensure that medication orders are transcribed appropriately upon admission. The Director of Nursing or designee will complete medication administration observations on 5 residents weekly for 4 weeks to ensure that medications are given per order. The results will be presented to the QAA committee for review and consideration for further corrective actions. This Plan of Correction is being prepared and executed because it is required by the provisions of the State and Federal regulations and not because Kingston of Ashland agrees with the allegations and citations listed on the statement of deficiencies. Kingston of Ashland maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Kingston of Ashland's written credible allegations of compliance. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Kingston of Ashland reserves all possible contentions and defenses in any civil or criminal actions or proceedings. Please accept the date of correction 4/17/2025 as the facility's credible allegation of compliance. Resident #348's orders for ergocalciferol and calcitriol were corrected at the time of discovery with no negative outcome noted. Resident #348 no longer resides in the center. The Director of Nursing or designee will review medication orders for residents that have been admitted since the date of survey exit through the date of compliance to ensure that medication orders were transcribed appropriately upon admission. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will educate licensed nurses on the electronic order entry process and transcription policy on or before 4/17/2025.