Failure to Prevent Significant Medication Errors for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure three residents were free from significant medication errors. One resident with a history of schizophrenia, bipolar disorder, insomnia, and severe dementia with agitation did not receive their prescribed monthly paliperidone (Invega) injections on two consecutive months. Documentation showed the medication was not available on the scheduled date, and there was no clear written communication or follow-up to ensure the dose was administered the following day. Additionally, when the resident refused the medication in the subsequent month, there was no documentation that the physician or nurse practitioner was notified, as required by facility policy. The resident subsequently exhibited increased behavioral issues, including threats and physical aggression, which staff acknowledged could be related to missed medication doses. Another resident with diagnoses including epilepsy, hypertension, and colitis did not receive their scheduled morning medications after requesting to take them post-breakfast. The LPN did not return to administer the medications after the resident finished eating and did not notify the physician, family, or DON of the omission. The resident later experienced elevated blood pressure and reported that they had not refused the medications but simply wanted to take them after eating due to previous adverse effects. The nurse confirmed she did not offer the medications again and failed to follow up as required. A third resident, who returned from the hospital with a PICC line and orders for intravenous antibiotics, did not receive all prescribed doses of Piperacillin-Tazobactam (Zosyn). Documentation in the electronic medication record indicated that several doses were either recorded as administered days after they were due, documented by staff not present at the time, or by staff not qualified to administer the medication. Pharmacy records showed a discrepancy between the number of doses delivered and those administered, with a significant number of unused doses found in the medication room. The medical director and other staff were not notified of the missed doses until after the resident was transferred back to the hospital for complications related to infection.