Failure to Administer Medications as Ordered Resulting in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for four out of seven residents reviewed, resulting in significant medication errors. In multiple instances, residents did not receive critical medications such as anticoagulants, anticonvulsants, antidiabetics, antibiotics, and pain medications due to the medications not being available at the facility. Documentation showed that doses of Lovenox and levetiracetam were missed for a resident with acute respiratory failure and seizures, with progress notes indicating the medications were not available and the pharmacy had not delivered them. The DON confirmed these omissions were due to unavailability of the medications. Another resident with acute osteomyelitis, sepsis, and diabetes mellitus did not receive several scheduled doses of Rybelsus and Bactrim, as these medications were also not available and not kept in the emergency drug kit. Progress notes repeatedly documented that the facility was awaiting delivery from the pharmacy, and the DON confirmed the medications were not available for administration for an extended period after admission. Additional missed doses occurred even after the medication was reportedly delivered, with no clear explanation provided. Further review revealed that two residents prescribed Methadone for chronic pain experienced both missed doses and administration errors. One resident received Oxycodone instead of Methadone, and another received an incorrect dosage of Methadone, both errors confirmed by the DON. These events were documented on Medication Error forms and verified through staff interviews and record reviews, demonstrating a failure to administer medications as ordered and to prevent significant medication errors.