Significant Medication Errors Due to Missed Administration and Falsified Documentation
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by six residents not receiving their scheduled medications on a specific evening shift. An agency LPN documented in the electronic medication administration record that all medications were given, but the next morning, multiple sealed medication packets were found unopened on the medication cart. The medications involved included treatments for conditions such as low blood pressure, Candida infection, epilepsy, hypertension, and muscle spasms. The residents affected had diagnoses including heart failure, symptomatic epilepsy, osteomyelitis, and hypertensive heart disease. Interviews with facility staff confirmed that the medications were not administered as documented. The DON reviewed the records and confirmed that the missed doses for the six residents constituted significant medication errors. One resident reported not receiving his night medications, including pain medication, and stated that the nurse did not return to his room despite his calls. The LPN involved later claimed to have experienced computer issues and signed off medications in the system after giving them, not realizing some remained on the cart. Other staff, including another LPN and the Registered Charge Nurse, corroborated that the unopened medication packets were found and that the affected residents were assessed for adverse consequences, with only one resident voicing a complaint. The facility's policy required that residents receive care and services safely and in an environment free of significant medication errors, which was not followed during this incident.