Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors in three distinct instances. For one resident with type two diabetes mellitus and severe cognitive impairment, staff did not rotate insulin injection sites as required. Documentation showed repeated administration of insulin in the same area of the abdomen over multiple days, despite care plan interventions and facility policy mandating site rotation. Both the LVN and DON confirmed that injection sites were not rotated, which was acknowledged as a medication administration error according to facility policy. Another resident with a history of pancreatic cancer and hypertensive heart disease did not receive prescribed medications, carvedilol and pancrelipase, at the times ordered by the physician. The resident reported not receiving these medications with breakfast as required, and the MAR confirmed administration times did not align with physician orders. The LVN and DON both stated that administering medications outside the prescribed timeframe is considered a medication error, and facility policy requires medications to be given within one hour of the scheduled time unless otherwise specified. In a third instance, an LVN was observed mixing eight crushed medications together and administering them all at once via a gastrostomy tube to a resident with parkinsonism and severe cognitive impairment. Facility policy and the LVN's own statements indicated that each medication should be administered separately with a water flush between each to prevent drug interactions and tube clogging. The DON confirmed that the medications were not administered correctly, as per facility policy, which defines such actions as a medication error.