Failure to Administer Medications as Ordered and Report Medication Errors
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with physician orders and did not identify or report medication errors for two residents. One resident, who had diagnoses including acute pain due to trauma and dorsalgia, was on a scheduled pain medication regimen and also received PRN pain medications. This resident had physician orders for miconazole nitrate 2% topical cream to be applied twice daily and tramadol 25 mg to be administered four times daily. Review of the medication administration records (MAR) showed multiple missed doses of both miconazole and tramadol, with documentation indicating the medications were unavailable on several occasions. There was no evidence in the progress notes that the provider was notified of these missed doses or the ongoing lack of medication supply, and the medication errors were not reported as required by facility policy. Another resident, with a history of chronic obstructive pulmonary disease (COPD), had physician orders for albuterol sulfate aerosol inhaler to be administered as two puffs four times daily. The MAR indicated that two doses of albuterol were missed due to the medication being unavailable. There was no documentation in the progress notes regarding the missed doses or provider notification. The DON confirmed that these missed doses were not reported as medication errors and that the medication was not administered as ordered. Interviews with the LPN and DON revealed that medications should be available for administration as ordered and that providers should be notified if medications are not available. Both staff members acknowledged that missed doses without a provider order to hold the medication constitute medication errors. Facility policies require that medication errors, including omissions, be reported and tracked for quality improvement, and that appropriate notifications be made to providers and residents or their representatives. Despite these policies, the facility did not identify, report, or document the medication errors for the affected residents.