Significant Medication Errors Due to Lack of Nursing Coverage
Penalty
Summary
Seventeen residents on the 500 hall did not receive scheduled medications as ordered by their physicians due to a lack of nursing staff assigned to administer medications. The affected residents had a range of significant medical conditions, including atrial fibrillation, congestive heart failure, hypertension, diabetes mellitus, bipolar disorder, schizophrenia, Parkinson's disease, and chronic pain, among others. The missed medications included critical drugs such as anticoagulants, antihypertensives, insulin, antipsychotics, anticonvulsants, and pain relievers, as documented in the Medication Administration Records (MARs) for the specified dates. The deficiency occurred when, after 10:30 PM, only two nurses remained in the facility to cover all units, and neither nurse was willing to take responsibility for the 500 hall after another nurse left at 11:00 PM. As a result, no medications were administered to residents on the 500 hall during the overnight shift. Interviews with staff revealed that the nurses did not want to assume additional assignments, and the interim DON was not contacted about the staffing shortage. The administrator was informed of the staffing issue and attempted to contact additional nurses but ultimately determined that the remaining staff was sufficient. The Medical Director was notified of the incident and confirmed that residents did not receive their scheduled medications. The administrator and Medical Director both acknowledged the missed doses, and the Medical Director reviewed the situation to assess for any significant changes in resident status. The MARs and staff interviews confirmed that the medications were not administered as ordered, resulting in significant medication errors for the affected residents.