Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors due to lapses in medication administration. One resident, a male with diagnoses including type 2 diabetes mellitus, schizophrenia, and hypertension, did not receive his ordered blood sugar checks or insulin for 21 out of 31 days in May. The resident attended an adult habilitation center Monday through Friday, where staff were not authorized to administer medications. Facility nurses documented the missed doses as the resident being away but did not notify the physician or ensure alternative arrangements for medication administration. The medical director and nursing staff were unaware that the resident was not receiving his prescribed blood sugar checks and insulin during his time at the center. Another resident, a male with a history of dysphagia, gastrostomy hemorrhage, muscle wasting, and hypertension, did not receive his scheduled dose of Metoprolol via gastrostomy tube at 4:00 p.m. on a specific date. The resident reported not receiving the medication, and the responsible nurse confirmed it was her duty to administer medications on time. The facility's policies require medications to be administered as ordered and for the physician to be notified if a dose is missed, but this protocol was not followed in this instance. Interviews with facility staff, including nurses, the medical director, the regional nurse consultant, and the administrator, confirmed that the expected practice was to administer medications as ordered and to notify the physician if a dose was missed. However, in both cases, the required medications were not administered as prescribed, and appropriate notifications were not made, resulting in significant medication errors for both residents.