Failure to Prevent Significant Medication Errors with Controlled Substances
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors related to the administration of controlled substances. Multiple instances were identified where residents either missed scheduled doses, received extra doses, or were administered medication at incorrect times. For example, one resident with chronic kidney disease and chronic obstructive pulmonary disease was prescribed Oxycodone every eight hours but missed doses on several days, while another resident with cervical disc disorder received four doses of Norco in one day instead of the ordered three. Additionally, a resident with alcoholic cirrhosis was supposed to receive Oxycodone once daily in the morning but was administered two doses on two separate days. Further review revealed that a resident with chronic pain syndrome and rheumatoid arthritis received five doses of Oxycodone in one day, exceeding the prescribed four doses, and there was a lack of documentation and physician notification regarding this error. The resident reported feeling overdosed and unable to stay awake following the incident. Another resident with chronic obstructive pulmonary disease and chronic kidney disease received both too many and too few doses of Oxycodone on different days, deviating from the physician's orders. In several cases, the errors were confirmed by staff interviews, and documentation on the controlled substance logs and medication administration records did not align with the prescribed regimens. The facility's policies required accurate documentation and prompt investigation of medication errors, but these were not consistently followed. In one instance, management was unaware of a medication error until it was brought to their attention by surveyors, and an incident report was not completed at the time of the event. The lack of timely documentation, notification, and investigation contributed to the ongoing risk of significant medication errors among residents receiving controlled substances.