Significant Medication Errors Due to Reordering Failures and Communication Breakdowns
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, resulting in actual harm to one resident and potential harm to another. One resident with a history of traumatic brain injury and epilepsy did not receive the physician-ordered anti-convulsant medication Vimpat for three consecutive doses due to a breakdown in the medication reordering process. The medication was not available because the required prescription was not received by the pharmacy, as the facility's fax machines were not functioning and staff did not follow up to confirm receipt or notify the physician of the missed doses. This resident subsequently experienced severe clonic tonic seizures, required emergency medical intervention, intubation, and transfer to a neuro ICU for ongoing care. Another resident with a diagnosis of stable burst fracture and paraplegia did not receive a scheduled Fentanyl transdermal patch for pain management. The medication was not administered because the facility failed to send the required prescription to the pharmacy, despite the pharmacy indicating that prior authorization was not the cause of the delay. The resident reported significant pain as a result of not receiving the medication. Staff interviews confirmed a lack of understanding and inconsistent practices regarding the reordering of narcotic medications, contributing to the missed doses. Documentation revealed that staff did not consistently document or communicate missed medication doses to physicians, and there was confusion among both facility and agency nurses about the correct procedures for reordering medications, especially when technical issues such as fax machine failures occurred. The facility's policies required medications to be administered safely and as prescribed, but these were not followed, leading to significant medication errors affecting at least two residents.
Removal Plan
- The facility pharmacy was contacted and delivered Resident #63's Vimpat to the facility.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to discuss the root cause analysis of Resident #63 not receiving Vimpat, staff education, and ongoing medication audits. The Administrator, DON, ADON, Social Services, Minimum Data Set Nurse, and Medical Director were in attendance.
- Regional Director of Clinical Services educated the DON, ADON, and Unit Manager on re-ordering resident medications.
- The DON and ADON completed a whole house audit to ensure all in-house residents had all ordered medications available.
- The Administrator/designee educated the nurses who were currently working on re-ordering of medications and the procedure if the fax machine was not functioning properly. All remaining nurses would be educated prior to the beginning of their next shift. Nursing leadership would add education to the nursing agencies the facility utilized to educate their staff on the facility's procedure of re-ordering medications and what to do if the fax machine was not working. Education would also be added to orientation for all new hire nurses. The facility also had a plan in place to hire a unit manager for night shift supervision.
- The Administrator checked the facility fax machines and all three were in working order.
- The DON/designee would audit all resident medications three times weekly for four weeks then two times weekly for two weeks, then one time for two weeks to ensure all in-house residents have all ordered medications available. Any concerns identified would be reviewed in Ad Hoc QAPI by the interdisciplinary team.
- Nursing leadership would ensure all resident medications would be re-ordered when no less than five days remaining of the medication. Nursing leadership would be responsible for providing any prior authorization requests to the physician and/or nurse practitioner and following up to ensure the prior authorization request was returned to pharmacy timely.
- Staff would contact the Administrator or nursing leadership to inform them if the fax machine is not working. If a prescription was needed, the physician and/or nurse practitioner would be contacted by staff or nursing leadership to request the prescription. Staff/nursing leadership would follow up with pharmacy to ensure the physician order was received.