Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two cases involving missed or incorrect medication administration. For one resident with diagnoses including Influenza A, hypoxemia, and sleep apnea, a physician order required Tamiflu to be administered on specific days. However, the medication was not available from the pharmacy, and the order was discontinued without the resident receiving the prescribed doses. This was confirmed by the Director of Nursing and the Nursing Home Administrator. In another case, a resident with respiratory failure, immunodeficiency, and kidney transplant rejection was ordered to receive 125 mg of cyclosporine every 12 hours following hospital discharge. Instead, the facility administered 100 mg of cyclosporine twice daily for 14 days, due to an error in order entry upon admission. This discrepancy was confirmed by the RN Supervisor and facility leadership, who acknowledged that the resident did not receive the medication as ordered during the specified period.