Failure to Notify Physician and Document Medication Error
Penalty
Summary
A medication error occurred involving a resident with severe cognitive impairment and multiple diagnoses, including unspecified dementia and a cognitive communication deficit, who resided on the memory care unit. The resident's family member discovered a cup containing the resident's evening medications left in the room and returned it to an LPN. The LPN identified the pills as the resident's missed evening medications from the previous night, disposed of them, but did not document the incident or notify anyone, including the physician. The Director of Nursing later confirmed that the expected procedure in such cases would be to complete a medication error report and notify the physician, but this was not done at the time of the incident. The facility did not have a policy for medication errors, and the required documentation and physician notification were not completed following the discovery of the missed medication dose. The failure to notify the physician and document the medication error was confirmed through staff interviews and record review. The resident was observed to be alert but confused, ambulating independently, and participating in activities at the time of the survey.