Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to prevent significant medication errors for three residents, as evidenced by missed or undocumented administration of prescribed medications. One resident with chronic pain and a history of left hip joint absence and shoulder deformity did not receive a scheduled dose of morphine sulfate because the LPN forgot to retrieve the medication while assisting another resident. Documentation indicated the resident was alert and able to verbalize pain, and the error was discovered during a narcotic count at the end of the shift. Another resident with back pain, osteoarthritis, and osteoporosis did not receive a scheduled dose of oxycodone due to the LPN being overwhelmed by the number of residents waiting for medication. The resident's pain level increased during this period, and the incident was documented as a medication error. A third resident with type 2 diabetes and morbid obesity did not have documentation of receiving prescribed sliding scale insulin after a blood sugar reading that required administration. Review of the Medication Administration Record confirmed the absence of documentation for the insulin dose. In all three cases, the medication errors were attributed to staff oversight or workload, and the facility's policy on medication errors was not followed as required.