Significant Medication Errors Due to Missed and Unaccounted Doses
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by missed and unaccounted doses of prescribed medications for two residents. One resident with multiple complex diagnoses, including hypertension and heart failure, had several documented omissions of Metoprolol 100 mg, a medication ordered to be given twice daily. The Medication Administration Record showed multiple missed doses over a one-month period, with some doses signed as given when the medication was not available. Pharmacy records indicated that sufficient medication had been delivered, but tablets were unaccounted for, and staff interviews revealed confusion regarding the availability and administration of the medication. The Assistant Director of Nursing confirmed that tablets delivered were not used as intended, and the Director of Nursing could not verify administration for several dates, especially when agency staff were involved. Another resident, with diagnoses including diabetes, chronic kidney disease, and frequent urinary tract infections, did not receive four out of fourteen ordered doses of intravenous Ertapenem Sodium for a UTI. The Medication Administration Record and infection tracking log confirmed the missed doses. The Director of Nursing verified the omissions and noted the resident's ongoing issues with UTIs and involvement of an infectious disease physician. These findings were substantiated through medical record review, staff interviews, observation, and policy review, demonstrating a failure to administer medications as prescribed.