Significant Medication Errors Affecting Multiple Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving four residents. One resident with insulin-dependent diabetes received a subcutaneous insulin injection in the deltoid muscle, an area lacking sufficient adipose tissue for safe subcutaneous administration, contrary to standard nursing procedures. The nurse involved was observed injecting the medication at a 90-degree angle into the deltoid, and both the nurse and nursing supervisor provided inconsistent or incorrect explanations regarding proper subcutaneous injection sites. Another resident with chronic kidney disease and metabolic acidosis experienced repeated missed doses of Sodium Bicarbonate due to the medication not being available in the medication cart. Documentation showed several doses were not administered over multiple days, with notes indicating the medication was missing or not in stock. The resident reported going days without the medication, and the facility's records confirmed the missed administrations. A third resident with hypertrophic cardiomyopathy and vascular dementia was administered Carvedilol despite blood pressure readings below the ordered parameters on several occasions. On one occasion, the nurse attempted to remove the Carvedilol tablet from a mixture of medications in applesauce after being reminded of the hold parameters, but discarded the wrong tablet and proceeded to administer the remaining medications. The resident subsequently experienced low blood pressure and decreased responsiveness. Additionally, a fourth resident with epilepsy missed multiple doses of Celotin due to the medication being unavailable, with documentation and interviews confirming the missed doses and the resident's concern about the impact on seizure control.