Significant Medication Errors in Administration of Antihypertensive, Hypotensive, and Insulin Medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors in three separate incidents involving antihypertensive, hypotensive, and insulin medications. In the first incident, a resident with hypertension and impaired cognitive skills was not administered their prescribed Norvasc (an antihypertensive medication) within the required timeframe. The medication was left at the bedside by an LVN, who became distracted and did not witness the resident ingesting the medication. The resident had not been assessed as safe for self-administration of oral medications, and facility policy required medications to be administered within 60 minutes of the scheduled time and for staff to observe ingestion. In the second incident, a resident with hypotension and moderately impaired cognition did not receive midodrine (a medication for low blood pressure) in accordance with the physician's prescribed parameters. Review of the Medication Administration Record and medication packaging revealed multiple instances where the medication was either given when it should have been held, held when it should have been given, or documentation did not match actual administration. The DON confirmed the importance of following prescribed parameters to prevent complications, and facility policy required medications to be administered as prescribed and in accordance with written orders. The third incident involved a resident with Type 2 Diabetes Mellitus who received 31 doses of expired Humulin N insulin from seven different licensed nursing staff over a period of more than two weeks. The expired insulin was not removed from the medication cart as required by facility policy and manufacturer guidelines, which state that Humulin N Kwikpen should be discarded 14 days after opening. The DON acknowledged that the expired insulin was administered and that this constituted a significant medication error. Facility policies required checking expiration dates prior to administration and prompt removal of expired medications.