Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were protected from significant medication errors, as evidenced by multiple incidents involving five residents. In each case, residents received either the wrong medication, the wrong dose, or missed their prescribed medication. For example, one resident with Alzheimer's disease, schizophrenia, and muscle spasms was prescribed lorazepam 0.5 ml twice daily for anxiety but was administered 1 ml on several occasions. Another resident with seizures and alcohol abuse was given another resident's Norco 5-325 mg instead of their prescribed Norco 10-325 mg. Similarly, a resident with arthritis and schizophrenia received another resident's Norco 10-325 mg instead of their own Norco 5-325 mg, and a resident with stroke and diabetes was also given the wrong dose of Norco. Additionally, a resident with schizophrenia, diabetes, and opioid dependence was supposed to receive lorazepam 1 mg daily for anxiety but was instead administered oxycodone 10 mg and did not receive their prescribed lorazepam. These errors were confirmed by the Director of Nursing (DON) through record review and staff interviews. The incidents were documented in Medication Error and Analysis reports, indicating a pattern of medication administration errors affecting multiple residents with complex medical histories.