Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to prevent significant medication errors for two residents by not adhering to physician orders and established medication administration protocols. For one resident with a history of hypertension and heart failure, a nurse administered Metoprolol and Amlodipine without first checking the resident's heart rate, despite clear physician orders to hold the medications if the heart rate was below 60 or systolic blood pressure was below 110. The nurse acknowledged not checking the heart rate prior to administration, which was confirmed during observation and interview. For another resident admitted with acute osteomyelitis and cellulitis, intravenous antibiotics Zosyn and Daptomycin were not administered as ordered on multiple occasions, as evidenced by blank entries on the Intravenous Medication Administration Record. Both the nurse supervisor and the Director of Nursing confirmed that the absence of documentation indicated the medications were not given. The facility's policy required medications to be administered according to physician orders, which was not followed in these instances.
Plan Of Correction
F760: Residents are Free of Significant Med Errors CORRECTIVE ACTION On 3/7/25, LVN 4 was provided 1:1 in-service regarding checking of heart rate and blood pressure prior to the administration of metoprolol and amlodipine. Don/Designee conducted in-service following the 5 rights of medication administration, which are the standard of safe practice. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/25/2025, the DON randomly followed nurses during med pass to check if residents were given metoprolol or amlodipine after heart rate was checked. No other residents were affected by the deficient practice. On 3/25/25, the DON conducted an in-service for the 5 rights in medication safe practices: > right patient > right dose > right route > right time > right drug And to follow up on the parameters for medications metoprolol and amlodipine and monitor heart rate and blood pressure. MEASURING AND SYSTEMIC CHANGES DON/Designee will perform random skill checks on licensed staff weekly to ensure that blood pressure and heart rate are checked prior to administering medications. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.