Failure to Prevent Significant Medication Errors for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors, as evidenced by late or omitted administration of critical medications. One resident with diabetes and renal impairment did not receive insulin as ordered before meals on multiple occasions. Documentation showed repeated late administration of insulin, sometimes several hours after the scheduled time and after meals had been consumed, with no rationale documented in the medical record. The resident expressed concern about the timeliness of insulin administration, and both nursing staff and the Director of Nursing confirmed that insulin should be administered as ordered, particularly before meals. Another resident with a history of stroke and hemiparesis did not receive a prescribed dose of Xarelto, an anticoagulant, during the morning medication pass. The nurse responsible for medication administration was unaware that the medication had not been given and confirmed that the resident had not declined the dose. The Director of Nursing acknowledged that this omission constituted a significant medication error. A third resident with diabetes, spinal stenosis, COPD, and bipolar disorder experienced repeated delays in the administration of fast-acting insulin (Fiasp) in accordance with physician orders. Observations and record reviews indicated that insulin doses were administered more than an hour after the scheduled times, including after meals had been consumed. The resident reported that medications were often forgotten or given late, particularly in the evenings. Facility policy required medications to be administered within one hour of the scheduled time, and staff interviews confirmed this expectation.