Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the omission and improper administration of prescribed medications for two residents. For one resident with multiple chronic conditions including diabetes, glaucoma, and chronic kidney disease, the morning dose of cilostazol was not administered because the medication was unavailable. Additionally, the resident received two different ophthalmic solutions for glaucoma without the required pause between administrations, contrary to facility policy, which specifies a waiting period to ensure optimal absorption. The nurse confirmed both the omission of cilostazol and the lack of pause between eye drop medications during interviews. Another resident, admitted with diagnoses such as femur fracture, schizophrenia, diabetes, and heart failure, did not receive the prescribed antidepressant vilazodone for three consecutive days due to the medication not being available in the facility. There was no documentation indicating that the medication was administered or that the physician was notified of the omission. The Director of Nursing confirmed the missed doses and the lack of medication availability. Facility procedures require medications to be administered as ordered and within a specific time frame, which was not followed in these cases.