Failure to Prevent and Document Double Dosing of Narcotic Medications
Penalty
Summary
A deficiency occurred when three residents received double doses of their scheduled narcotic pain medications due to failures in medication administration and documentation. Specifically, a medication aide administered narcotic pain medications to three residents but did not sign off the administration in the electronic medical record (EMR), only on the narcotic count sheet. The aide wrote the medication administration on a piece of paper and gave it to the nurse on the next shift, who subsequently forgot about the note and, seeing the medications still due in the EMR, administered a second dose to each resident. Both staff members acknowledged they had been trained that the person administering the medication is responsible for signing off in both the EMR and the narcotic count sheet. The residents involved had complex medical histories, including dementia, chronic pain, and other significant diagnoses. The double dosing of narcotic medications was not documented in the residents' progress notes, and there was no follow-up monitoring of the residents for adverse effects after the error. Additionally, responsible parties for the residents were not notified of the medication errors, and the errors were not included in the 24-hour report to inform subsequent shifts. The facility's policy required prompt reporting of medication errors, detailed documentation, and close monitoring of affected residents, none of which were followed in this incident. Interviews with facility staff, including the DON, administrator, and medical director, confirmed that the required documentation, monitoring, and notifications were not completed. The medical director expressed concern about the lack of follow-up monitoring, stating that vital signs and respiratory status should have been checked due to the risk of narcotic overdose. The failure to adhere to established medication administration and error reporting protocols led to the identification of an Immediate Jeopardy situation by surveyors.
Removal Plan
- Responsible parties for Residents #1, #2, and #3 were contacted and made aware of the med errors.
- The Medical Director was made aware of past med error.
- Missed Medication Report was pulled to ensure no other residents were administered narcotics twice.
- Review of all Narcotic sheets was completed to ensure that there were no double doses of narcotics based on the sign out sheets and comparing to nurse notes and EMARs.
- ADONs are reviewing count sheets daily to ensure no double doses have been administered.
- The Chief Operating Officer and Director of Clinical Operations educated the DON and Administrator with a posttest to show understanding.
- The Director of Nurses provided training to the nurses and medication aides on duty with a post test to show understanding.
- Training for nurses and med aides on duty was provided with a post test to show understanding.
- Training was concluded for all staff on-site.
- Training will be concluded for those not present; they will be educated and required to pass a post test before they take their next assignment.
- New hires will receive training from the DON or designee during new hire orientation.
- The person who made the error(s) received an in-service and a disciplinary action.
- Residents with med errors were assessed and all notifications were made and documented by the ADON and CHARGE NURSE.
- Ad-Hoc QAPI meeting was held to discuss medication errors and failure to document; in-services over administering medications, medication errors, and notifications and reviewed post test for administering medications.
- Missed Medications report will be run during daily stand-up meeting to review medications that were missed.
- Any medication errors, the staff member will be contacted and an in-service and disciplinary action (where necessary) will be initiated.
- All nursing staff who administer medications will be given reminder education over the policy and procedures by the DON or Nurse Managers that will be initiated immediately following the med error until all staff who administer medications has received re-education.
- The ADONs are reviewing count sheets to ensure no one has been double dosed or that a dose has been missed and not documented in the EMAR. This is part of their morning routines.
- Missed Medication Report will be run prior to daily stand-up meeting by the DON. This will be an ongoing process.