Failure to Prevent Significant Medication Errors and Ensure Accurate Medication Reconciliation
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the areas of medication reconciliation upon admission and the administration of physician-ordered medications. In one case, a resident with a history of seizures and a gastrostomy tube was readmitted from the hospital with orders for a specific dose and form of seizure medication (Levetiracetam/Keppra). The facility did not accurately reconcile the hospital discharge medication orders, resulting in the resident receiving an incorrect dose and form of the medication. Documentation showed confusion and delays in changing the medication from tablet to solution for G-tube administration, and there was a lack of clear communication and documentation regarding dose changes. The resident subsequently experienced multiple seizures, a fall with head trauma, and was transferred to a higher level of care, where he later died. Additionally, physician-ordered laboratory tests for seizure medication levels were not implemented as ordered, with no results found in the medical record. Another resident, also with a history of seizures and a feeding tube, was readmitted with hospital discharge orders for multiple medications, including two anti-seizure drugs and other critical medications. The facility failed to obtain and reconcile the correct hospital discharge medication list, resulting in the omission of key medications, including a prescribed seizure medication. The resident did not receive the ordered anti-seizure medication, and there were multiple missed doses of another seizure medication due to unavailability. The resident subsequently experienced seizure-like activity and required transfer to a higher level of care. Interviews revealed that the admitting nurse did not verify the medication list with the physician, and the correct discharge medication list was not obtained until after the incident. A third resident with diabetes and epilepsy was affected by improper medication administration when an LPN administered two large doses of insulin without a physician's order, contrary to the resident's sliding scale insulin protocol, which required physician notification for high blood sugar readings. The nurse did not document the blood sugar readings or the insulin administration and failed to notify the physician as required. The resident was later sent to the hospital for hyperglycemia and influenza A. Interviews confirmed that the nurse acted outside the scope of practice and did not follow established protocols for medication administration and physician notification.