Failure to Prevent Significant Medication Errors
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, as evidenced by multiple instances where medications were not administered as ordered or were given inappropriately. For example, one resident with diabetes, COPD, and atrial fibrillation had a physician's order for Tobradex ophthalmic ointment to be administered four times daily for conjunctivitis, but several doses were missed over multiple days without proper documentation or notification to the medical provider. The medication administration record listed reasons such as 'clinical monitoring' or 'within normal range,' but there was no supporting documentation in the progress notes, and nursing staff could not explain the rationale for these omissions. Another resident with severe cognitive impairment and a diagnosis of cellulitis was prescribed Rocephin injections for five days, but only four doses were administered due to a reported lack of lidocaine, which was not verified by staff. There was no documentation that the physician was informed of the missed antibiotic dose, nor was there any adjustment to the medication schedule to compensate for the missed dose. Staff interviews confirmed that the provider should have been notified and that such communication should have been documented in the resident's progress notes. Additionally, a resident with right hemiplegia, Parkinson's disease, and muscle weakness received 40 units of Lantus insulin without a physician's order, as documented in both the medication error report and hospital records. The resident's medication administration record did not include an order for insulin, and the incident was only discovered after the resident exhibited symptoms of hypoglycemia. Staff interviews confirmed that nurses are trained to follow the six rights of medication administration, but this protocol was not followed in this instance.