Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to prevent significant medication errors for two residents, both of whom experienced missed or delayed administration of critical medications. One resident, with diagnoses including chronic atrial fibrillation, diabetes, and neuropathy, was admitted in the late afternoon and did not receive her scheduled doses of apixaban (an anticoagulant), Lantus insulin, and pregabalin (for neuropathy) on the evening of admission. The nurse on duty did not have access to the facility’s back-up medication supply and was waiting for pharmacy delivery, which did not arrive that night. The resident’s blood sugar was elevated the following morning, and she reported not receiving her neuropathy medication for several days, which was confirmed by multiple missed doses documented in the MAR over the next four days. The pregabalin was not administered until a new prescription was obtained several days after admission, as the pharmacy required a prescription for this controlled substance and none was provided at admission. Multiple staff interviews revealed that nurses were unable to access the emergency medication supply due to lack of a prescription and that communication lapses occurred between nursing staff, the pharmacy, and the prescribing providers. The facility’s pharmacy had a cutoff time for medication orders, and the initial orders for the resident’s medications were received after this cutoff, resulting in further delay. The facility’s NP and physician confirmed that the prescription for pregabalin was not written until several days after admission, and the pharmacy did not receive the necessary order to dispense the medication until then. The resident missed a total of eight doses of pregabalin before it was finally administered. A second resident was readmitted to the facility after a hospital and short-term rehabilitation stay, with transfer paperwork indicating an active order for the antibiotic linezolid to treat a urinary tract infection. Upon readmission, the nurse on duty did not reconcile the new orders and continued administering medications from the resident’s previous stay, missing the new antibiotic order. The antibiotic was not ordered at the facility until the following day, and further delays occurred due to a pharmacy backorder and the need to resolve a potential drug interaction. As a result, the resident missed three scheduled doses of linezolid before receiving the first dose. Staff interviews confirmed that the missed doses were due to lack of order reconciliation, pharmacy delays, and communication issues.