Significant Medication Errors Resulting in Actual Harm
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first case, a resident with osteoporosis, hip fracture, and arthritis was prescribed Fosamax 70 mg once every seven days, but due to an error in order entry by a registered nurse, the medication was administered daily for five days within a seven-day period. This error was discovered after the resident had already received multiple incorrect doses, prompting notification of the provider and the resident's family, who requested hospital evaluation. In the second incident, another resident with a history of coronary artery disease, Alzheimer's disease, and cerebrovascular accident received a full set of medications intended for a different resident. The medications included a combination of narcotics, blood pressure medications, anticoagulants, diabetic medications, and others. The error was identified after the resident exhibited symptoms such as hypoxia, vomiting, bradycardia, hypotension, and altered mental status. Emergency services were called, and the resident required administration of Narcan, atropine, and IV fluids before being transferred to the hospital for further observation and management. Interviews with staff revealed that the LPN responsible for the second incident was distracted during medication administration and was not adequately trained on using resident photos for identification or on best practices such as bringing the medication cart to each resident's room. The facility's policies required verification of the five rights of medication administration and use of two identification methods, but these procedures were not followed, resulting in significant medication errors and actual harm to the residents involved.