Significant Medication Administration Errors Due to Late and Improper Dosing
Penalty
Summary
Multiple residents experienced significant medication administration errors, including late administration of critical medications and improper insulin administration techniques. For example, one resident with diabetes mellitus and diabetic nephropathy received insulin after consuming breakfast, and the LPN failed to check blood sugar prior to the meal and did not prime the insulin pen before administration. Another resident with type two diabetes mellitus received insulin after breakfast, but the blood sugar was checked only after the meal, contrary to care plan interventions requiring blood sugar monitoring before meals. Several residents with complex medical conditions, such as congestive heart failure, COPD, hypertension, and diabetes, had their scheduled medications administered several hours late on multiple occasions. Medications affected included metoprolol, Entresto, Lasix, Ativan, gabapentin, spironolactone, Macrobid, Colchicine, Eliquis, trazodone, insulin Lispro, insulin Glargine, Depakote, Tamsulosin, and others. These late administrations were confirmed by both medical record review and interviews with the DON, who acknowledged that medications were given outside the facility's policy window of 60 minutes before or after the scheduled time. Residents also reported receiving medications late, sometimes receiving multiple scheduled doses together, such as morning and noon medications at the same time. The facility's own policy required medications to be administered within a specific time frame, but this was not consistently followed. The DON confirmed that these late administrations constituted medication errors, and the deficiency affected multiple residents reviewed for medication administration.