Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. For one resident with multiple complex diagnoses, including heart failure and hypertension, there were two overlapping physician orders for furosemide: one for 20 mg twice daily and another for 60 mg once daily. Both orders were active simultaneously, resulting in the resident receiving both dosages on two consecutive days before the orders were discontinued. The Director of Nursing confirmed that the previous order was not discontinued before the new one was started, leading to the resident receiving both medications concurrently, which should not have occurred. In another case, a resident with diabetes, schizophrenia, and other conditions was prescribed hydralazine for blood pressure management, but due to a nurse's error, hydrochlorothiazide was entered and administered instead. The error was discovered after several days, and the correct medication was then started. The nurse who made the entry error was identified, and it was confirmed that the wrong medication had been given. The facility's medication administration policy requires medications to be administered as ordered by the physician and in accordance with professional standards, but this was not followed in these instances.