Significant Medication Error Resulting in Hospitalization
Penalty
Summary
A resident with chronic obstructive pulmonary disease and congestive heart failure was admitted to the facility and had physician orders for lasix to manage fluid buildup. The resident's lasix regimen was changed from once daily to twice daily for five days due to increased swelling, requiring the original order to be stopped. Due to a charting error on the medication administration record (MAR) and a reported glitch in the computer system, the resident did not receive lasix for four consecutive days. The nurse responsible for the medication change was unable to place the medication on hold in the system, discontinued the original order, and communicated her concerns to the provider and care manager, but assumed the issue would be addressed by others during clinical rounds. As a result of not receiving lasix, the resident developed significant clinical symptoms, including increased swelling, shortness of breath, and lowered oxygen levels. The resident was subsequently hospitalized for acute hypoxemic respiratory failure, with hospital records indicating volume overload and elevated BNP levels attributed to medication non-adherence. The facility confirmed the medication error and its impact through internal investigation and communication with the State Survey Agency.