Significant Medication Errors Due to Unstaffed Nursing Shift
Penalty
Summary
On 2/25/2024, the facility failed to ensure that residents were free from significant medication errors when there was no nurse present on the second floor during the 7 AM to 3 PM shift. As a result, 36 out of 42 residents on the unit did not receive their scheduled medications, with 30 of these residents missing significant medications. The medications omitted included antihypertensives, retrovirals, anti-seizure drugs, antidepressants, antidiabetics, insulin, narcotics, anticoagulants, antibiotics, immunosuppressants, anti-Parkinsonism, and antipsychotics. Specific residents affected included individuals with complex medical histories such as Type 2 Diabetes Mellitus, Essential Hypertension, Cerebral Infarction, Peripheral Vascular Disease, Atrial Fibrillation, Vascular Dementia, and Chronic Kidney Disease. For example, one resident missed doses of Losartan, Clopidogrel, Paroxetine, Metoprolol, and two types of insulin; another missed Clopidogrel, Lisinopril, Glucophage, Levemir, and Novolog. Other residents missed critical medications for heart failure, diabetes, hypertension, deep vein thrombosis, and more. The absence of a nurse was not communicated to facility leadership in a timely manner. The DON was unaware of the staffing gap until after the incident, as the nursing supervisor did not report the sick call or the lack of coverage. The administrator was informed by the supervisor that everything was fine, and the scheduler was not contacted for additional staffing. The medication errors were only discovered after the fact, when the DON returned to work and was notified by the Assistant DON.