Failure to Administer Medications as Ordered for Two Residents
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for two residents, resulting in significant medication errors. In the first instance, a resident with multiple diagnoses including heart failure, coronary artery disease, wound infection, and diabetes mellitus, who was totally dependent on staff for several activities of daily living, was given another resident's medications in error. This occurred because the resident did not have a profile picture on file, no name tag on the door, and was responding to the other resident's name during the medication pass. The medications administered included several with potential for serious side effects, such as antipsychotics, anticonvulsants, and antihypertensives. Following the error, the resident became lethargic, developed increased confusion, and was ultimately sent to the hospital for further management after a decline in vital signs and mental status. The incident was attributed to human error and a failure to properly identify the resident prior to medication administration. Staff interviews revealed that the nurse responsible was overwhelmed by workload and distractions, leading to a lapse in following the required verification steps, such as confirming the resident's identity and cross-checking medications. The nurse admitted to not adhering to the 'five rights' of medication administration and acknowledged that the error could have been prevented by slowing down and double-checking the resident's identity. The Director of Nursing confirmed that the root cause was the failure to properly identify the correct resident. In a separate incident, another resident with a history of coronary artery disease, heart failure, and diabetes mellitus received the wrong dose of insulin during a medication pass. The nurse administered 12 units of Aspart insulin instead of the ordered 15 units plus an additional sliding scale dose, resulting in a total underdose. The nurse was unable to recall the correct dose and reported difficulty due to being assigned to different units during the shift. The care plan for this resident did not include specific instructions for staff to double-check insulin doses. The Director of Nursing verified that the resident should have received a higher total dose than was administered.