Failure to Prevent and Report Significant Medication Errors
Penalty
Summary
The facility failed to ensure that significant medication errors were prevented for one resident with multiple diagnoses, including dementia, diabetes, hypertension, depression, and anxiety. The resident was not cognitively intact and had several physician orders for medications to be administered at specific times. Review of the Medication Administration Record (MAR) from June to August showed that the resident did not receive multiple morning medications on numerous days, with the reason documented as the resident being asleep. There was also one instance of medication refusal. The resident's care plan directed staff to administer medications as ordered and to monitor and document effectiveness and side effects, including over-sedation and lethargy, and to notify the physician as indicated. Despite repeated missed doses, there was no documentation in the medical record regarding the effects of the missed medications or any notification to the physician until mid-August, when an SBAR was submitted noting the resident's preference to sleep in. The Chief Nursing Officer confirmed that there was no documentation or physician notification regarding the missed medications prior to this date. Additionally, the facility did not have a policy specifying when the physician should be notified about missed medications, but acknowledged that best practice would have been to notify the physician within 24-48 hours.