Significant Medication Errors Due to Inadequate Verification and Competency
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by incidents involving two residents. One resident with diabetes and restless leg syndrome was administered the incorrect insulin by a Med-Tech who did not have documented competency in insulin administration. The error was discovered after the resident's blood sugar was closely monitored and various interventions were implemented to maintain safe glucose levels. The Med-Tech involved had not completed a skills check-off for insulin, and it was later acknowledged that oversight of the Med-Tech's competencies was lacking. Another resident with chronic pain, anxiety, and dementia did not receive a prescribed dose of Oxycodone-Acetaminophen as ordered for pain management. The omission was identified during a narcotic reconciliation, revealing that the resident had requested to take the medication at a later time but ultimately did not receive it. Both incidents were documented in the facility's incident and accident reports and involved failures in verifying the medication administration record (MAR) and adhering to the five rights of medication administration.