Failure to Administer Critical Medications Due to Order Entry and Communication Errors
Penalty
Summary
A significant medication error occurred when a resident did not receive five consecutive daily doses of Metoprolol Succinate, prescribed for heart failure, and Quetiapine Fumarate, an antipsychotic medication. The resident was admitted with multiple diagnoses, including chronic systolic heart failure, diabetes with peripheral angiopathy, hypertensive heart disease, and dementia with agitation. Upon admission, the Assistant Director of Nursing (ADON) entered and reactivated medication orders in the electronic medical record, but the process used did not result in the pharmacy being notified to send the medications. Documentation in the Medication Administration Record (MAR) and electronic MAR progress notes showed that the medications were consistently not available for administration over several days. Multiple agency nurses documented the missed doses, citing unavailability of the medications. Interviews revealed that agency nurses did not have access to the facility’s pyxis (backup medication supply) and were unaware of the process to obtain medications from it or to contact staff with access. The ADON, who was new to long-term care, believed that reactivating old orders in the system would suffice, but this did not trigger the pharmacy to deliver the medications. The resident’s vital signs remained within normal limits during the period of missed doses, and assessments by the Nurse Practitioner indicated no acute distress or behavioral issues. However, both the facility pharmacist and Nurse Practitioner confirmed that missing multiple doses of Metoprolol Succinate could be significant for a resident with heart failure. The Director of Nursing stated that all new admission orders should be entered as new orders and that the pyxis contained general medications for all residents, but agency nurses did not have access. The deficiency resulted from a combination of improper order entry, lack of pharmacy notification, and insufficient communication and access to backup medication supplies among agency staff.