Significant Medication Errors Due to Order Transcription and Administration Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving anticonvulsant medications. In the first case, a male resident with epilepsy and severe cognitive impairment was admitted with an order for phenytoin sodium extended-release capsules, 300 mg at bedtime. However, due to a transcription error by an LVN, the order was entered as 900 mg at bedtime, resulting in the resident receiving a triple dose for seven consecutive nights. This error was not identified during the daily morning meetings where new admission orders were supposed to be reviewed by the ADONs and DON. The resident subsequently developed symptoms consistent with phenytoin toxicity, including altered mental status, ataxia, and slowed speech, and was sent to the hospital where a toxic phenytoin level was confirmed. In the second incident, a female resident with a seizure disorder and moderate cognitive impairment had an order for carbamazepine to be administered as 400 mg in the morning and 100 mg at bedtime. The medication was only available in 200 mg tablets, and on at least one occasion, the resident received 200 mg at bedtime instead of the ordered 100 mg. Nursing staff were inconsistent in their administration practices, with one LVN stating she did not break tablets before crushing them, while another reported cutting the tablet in half. The resident's care plan did not address carbamazepine use, and the MAR reflected the incorrect administration. Both incidents revealed failures in medication reconciliation, order transcription, and verification processes. Staff interviews indicated a lack of consistent review and double-checking of new admission orders, as well as discrepancies between medication orders, MARs, and actual medication administration. The facility's policies required verification of medication orders and reconciliation with hospital records, but these procedures were not effectively implemented, leading to significant medication errors for the residents involved.
Removal Plan
- Licensed nurse completed a head-to-toe assessment, vital signs and neurological check on Resident #235 and findings revealed no abnormalities noted. Attending physician was notified and no new orders were given.
- Director of Nursing and/or Designee completed medication reconciliations to ensure that medications are given as ordered and documented on the MAR.
- Director of Nursing and/or designee conducted a review of all residents' changes in conditions, changes in level of care and signs and symptoms that possibly could have been medication toxicity. None was identified.
- Director of Nursing and/or designee conducted a review of all admissions/readmissions and ER visits to ensure medication orders are reconciled.
- Director of Nursing and/or designee conducted a toxicity Monitoring orders for all drugs with narrow therapeutic range and were added to EMAR.
- DON and/or Designee completed 100% medication reconciliation and MAR to Cart audit to ensure that medication on hand matches order and are administered as ordered.
- All licensed nurses were re-educated by the Director of Nursing or designee on the following: Abuse/Neglect and Exploitation, Medication Administration Policy and Seven Rights of medication administration, Medication Reconciliation, Change of Condition-signs/symptoms of medication toxicity and Md/RP notifications, Clinical Admission Process in EMR, 2 nurse verification on all new admission/readmission orders.
- 100% licensed nurses were re-educated on the following: Medication Administration Policy and Seven Rights of medication administration, Medication Reconciliation on new and medication order changes, Verification of medication label prior to medication administration.
- Licensed nurses who are out on PTO/ FMLA/ Leave of Absence will have the re-education completed prior to the start of their next scheduled shift.
- Newly hired licensed nurses will receive this training during orientation prior to providing care to residents. The training will include the above-stated educational components.
- Admission/readmission/new and medication order changes will be reviewed during the morning clinical meeting to ensure orders have been reconciled with hospital records and verified with physician. New and medication order changes will be reviewed to ensure medication is administered as ordered to include verification of medication label to match physician's orders. Review will also ensure that monitoring of adverse effects is ordered, completed, and documented and physician is notified for abnormal findings.
- Weekend RN and/or ADON will complete and review Medication reconciliation for admission/readmissions/new orders/medication order changes over the weekend.
- Director of Nursing will monitor compliance with medication administration policy and the seven rights of medication administration.
- Director/Designee will monitor compliance each weekday morning of new admission/readmission reconciliation completion and review medication order listing report to ensure new and changed medications are administered as ordered.
- Administrator will attend the morning clinical meeting to ensure the Director of Nursing and/or designee reviews the order listing and medication reconciliation process is followed during clinical meetings.
- An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the plan of removal.