Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving two residents. One resident with diagnoses of dementia and depression, and with intact cognition, did not receive her prescribed Ativan for several consecutive nights due to the medication being out of stock and the prescription having expired. Multiple progress notes documented the unavailability of the medication, communication with the pharmacy, and the need for a new prescription. Despite these issues being noted by various nursing staff, the resident went without her medication for at least four nights, and the issue was not promptly resolved. The resident herself reported not receiving her sleeping medication and experiencing difficulty sleeping as a result. In a separate incident, another resident with anxiety and dementia was almost administered the wrong dose and medication. During a medication pass, an RN obtained a 50 mg Hydroxyzine tablet from a medication card labeled for a different resident and added it to the medication cup for the intended resident, who was only prescribed 25 mg. The error was caught by a surveyor before administration, and the RN acknowledged not checking the name or dosage on the medication card prior to preparing the medication. These events demonstrate lapses in medication administration procedures and verification processes.