Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two cases involving medication administration. In the first case, a resident with brittle diabetes did not receive insulin according to the most recent physician orders. The resident's endocrinology summary included a revised sliding scale for Novolog insulin, but the Medication Administration Record (MAR) did not reflect these updated orders, and nursing staff continued to follow the outdated scale. The Assistant Director of Nursing confirmed that the revised orders from the endocrinologist were not implemented, resulting in the resident not receiving the correct insulin doses as prescribed. In the second case, a resident with multiple diagnoses, including hepatic encephalopathy, did not receive both scheduled doses of the antibiotic Rifaximin on a specific day because the facility had run out of the medication. The Assistant Director of Nursing stated that the medication was not available due to a failure to reorder it in advance, as required. The facility's policy requires that all medication orders be accurately documented and administered according to the five rights of medication use, but these procedures were not followed in these instances.