Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were protected from significant medication errors, as evidenced by the administration of incorrect medication dosages to three residents. For one resident with a right femur fracture and cognitive communication deficit, the MAR showed that Oxycodone was administered at a higher dose than ordered for the reported pain level on multiple occasions, contrary to the physician's specific instructions regarding pain scale and dosage. Another resident with orthopedic aftercare, diabetes, and cognitive communication deficit received Oxycodone at a higher dose than prescribed for their documented pain level, again not following the physician's order for pain management. A third resident, diagnosed with Wegener’s Granulomatosis with renal involvement and morbid obesity, was prescribed Midodrine to be held if systolic blood pressure exceeded 120. Despite this, the MAR documented multiple instances where the medication was administered when the resident's systolic blood pressure was above the specified threshold. These actions were confirmed by facility nursing leadership upon review of the records, indicating that the physician's orders were not followed in these cases.