Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first case, a resident with multiple diagnoses, including a left leg fracture and chronic pain, was ordered to receive 5 mg of Oxycodone every three hours. However, the resident was administered 10 mg of Oxycodone, which was intended for her roommate, due to the nurse pulling and administering medications for both residents at the same time. The facility's policy required verification of medication and resident identity prior to administration, but these procedures were not followed, resulting in the medication error. In the second case, a resident with diabetes was ordered to receive specific doses of Insulin Lispro according to a sliding scale and a separate order for Lantus SoloStar insulin. The resident was given the incorrect type of insulin after the nurse became distracted by questions from family members during medication administration. The facility's policy required staff to confirm medication orders and verify medications before administration, but this was not adhered to, leading to the administration of the wrong insulin. Documentation of staff training following this incident was requested but not provided.