Significant Medication Errors: Epogen Administered Outside Physician Parameters
Penalty
Summary
The facility failed to ensure that two residents were not administered Epoetin Alfa-epbx (Epogen) injections outside of the parameters specified in their physician orders. Both residents had orders to hold Epogen injections if their hemoglobin (Hgb) levels exceeded 10 g/dl. Despite these clear instructions, staff administered multiple doses of Epogen to both residents when their Hgb levels were above the prescribed threshold. One resident, with a history of end stage renal disease, dependence on dialysis, and anemia, received 19 unnecessary doses of Epogen over a period when their Hgb level was documented at 11.5 g/dl. The medication administration records and interviews with licensed vocational nurses revealed that the nurses did not check the most recent Hgb levels or review the physician's order before administering the medication. The nurses acknowledged that they failed to follow the order to hold the medication and recognized this as a medication error. Another resident, with a history of kidney transplant and anemia, received three unnecessary doses of Epogen when their Hgb levels were 12.3 g/dl and 12.9 g/dl. The nurse responsible admitted to not checking the latest Hgb level or reading the physician's order accurately before administration. The Director of Nursing confirmed that the facility did not follow the physician's orders and that licensed nurses were required to check current Hgb levels before administering Epogen. Facility policy required medications to be administered as prescribed, including adherence to any parameters set by the physician.
Removal Plan
- Notify the pharmacist regarding Resident 35 receiving extra doses of Epogen injections.
- Communicate with the Nephrologist to have the dialysis center administer Epogen injections based on lab work during dialysis treatments.
- Follow up with Resident 35's Primary Physician to clarify the order for Epogen to be given at the dialysis center.
- Assess Resident 35 for overall health condition and status.
- Notify Resident 89's Primary Physician regarding Resident 89 receiving extra doses of Epogen injections when Hgb was above the prescribed parameter.
- Continue the Epogen order for Resident 89 with the same parameter (hold Epogen injections when Hgb > 10 mg/dl), pending a complete blood count result.
- Notify the pharmacist regarding Resident 89 receiving Epogen injections when Hgb was above the prescribed parameter.
- Assess Resident 89 for overall health condition and status.
- Notify the Medical Director of the Immediate Jeopardy and develop a removal plan.
- Notify all licensed nurses of the Immediate Jeopardy findings and provide in-services regarding the Medication Administration policy and procedure, including checking/verifying resident and medication information, holding/discontinuing medication per parameters, and notifying physicians of medication-related issues.
- Notify the specific RN and LVNs responsible for the identified findings and provide one-on-one in-services regarding medication administration policy, focusing on Epogen injection administration based on parameters, following disciplinary action.
- Complete in-services regarding medication administration policy and procedure for all licensed nurses.
- Initiate a Quality Assurance and Performance Improvement (QAPI) plan to address the findings.
- Review all current residents with Epogen injection orders.
- Provide in-service regarding medication administration policy and procedure for all licensed nurses.
- Review all residents with Epogen injection orders, medication administration records, and laboratory results after admission, then weekly and as needed to ensure compliance.
- Create an Epogen injection administration log including resident name, Epogen injection order, medication administration following parameter, and laboratory monitoring.
- Review all residents with Epogen injection orders, medication administration records, and laboratory results after admission, then weekly and as needed, and document findings with corrective action on the monitoring log.
- Review the QAPI program and adjust measures to ensure effective and ongoing compliance with State and Federal regulations.