Failure to Prevent Significant Medication Errors in Medication Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. For one resident with multiple diagnoses including heart failure and Alzheimer's disease, staff did not obtain daily weights as ordered by the physician on multiple occasions. Additionally, when the resident experienced weight gains greater than three pounds in 24 hours, the as-needed Lasix was not administered as prescribed. The Director of Nursing confirmed that both the daily weights and the administration of Lasix were not completed according to physician orders. Facility policy required medications to be administered safely, timely, and as prescribed, which was not followed in this case. In another incident, a resident with type two diabetes mellitus and moderate cognitive impairment was ordered to receive Humalog insulin via pen, including a sliding scale for blood sugar regulation. During observation, an RN administered insulin without priming the insulin pen as required by manufacturer instructions. The RN acknowledged the omission during a concurrent interview. Facility policy indicated that nursing staff should have access to manufacturer instructions for insulin administration. These failures were identified during a complaint investigation and had the potential to affect additional residents receiving insulin via pen.