Significant Medication Errors Due to Documentation and Communication Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving the administration of anticoagulants, insulin, and narcotic pain medications. In one case, a resident with intact cognition and a physician order for Warfarin received a double dose due to a lack of communication and documentation between nursing staff and a medication aide during a shift change. The nurse administered the medication but did not document it, leading the medication aide to administer a second dose. This resulted in the resident receiving 8 mg instead of the prescribed 4 mg of Warfarin. Another incident involved a resident with diabetes who was prescribed sliding scale insulin. The LPN checked the resident's blood sugar and administered insulin after the resident had already eaten, contrary to the physician's order to administer insulin before meals. The blood sugar was recorded at 200 mg/dL, and 2 units of insulin were given, but the timing did not align with the prescribed protocol. A third resident, also with intact cognition, was prescribed oxycodone for chronic pain. Due to a similar breakdown in communication and documentation, both an LPN and a medication aide administered a 5 mg dose of oxycodone, resulting in the resident receiving a double dose. Additionally, a resident with severe pulmonary hypertension was prescribed Apixaban following hospital discharge, but a transcription error led to the incorrect entry of the medication order. The facility failed to clarify the discharge instructions with the hospital, resulting in the resident receiving an incorrect dosing regimen. These incidents were confirmed through interviews, record reviews, and direct observation, and were not in accordance with the facility's medication administration policy.