Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
Facility staff failed to ensure that two residents were free from significant medication errors. For one resident with diagnoses including dementia and schizophrenia, staff did not administer Risperdal Consta injections every two weeks as ordered by the physician. The medication was missed on multiple occasions, with gaps between doses and no oral antipsychotic coverage provided despite manufacturer recommendations for missed doses. Documentation showed that the medication was sometimes not available, and there was a lack of follow-up to ensure timely administration. Interviews with nursing staff revealed uncertainty about who was responsible for managing the resident's psychiatric medications and inconsistent notification of the appropriate parties when the medication was unavailable. For another resident with a history of alcohol abuse, anemia, hypertension, and cognitive deficits, staff failed to administer Midodrine according to the physician's parameters. The order specified that the medication should be held if the systolic blood pressure was above 110, but there were multiple instances where blood pressure was not assessed before administration, or the medication was given despite readings above the specified threshold. Review of the medication administration records for several months showed repeated failures to follow the prescribed parameters, including both missed assessments and inappropriate administration. Interviews with the unit manager confirmed that staff did not consistently follow the required procedures for medication administration, including checking blood pressure before giving Midodrine and holding the medication when parameters were not met. The deficiencies were brought to the attention of the facility administrator, but no additional information was provided at the time of the survey.