Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
Resident #28, who has diagnoses including type two diabetes mellitus, bipolar disorder, and anxiety disorder, experienced significant medication errors related to the administration of Glipizide and Ziprasidone. The physician's orders specified that Glipizide extended release should be taken 30 minutes before meals and Ziprasidone should be taken with meals. However, the Medication Administration Record (MAR) showed that Glipizide was scheduled for 9:00 A.M., which was after the unit's breakfast time of 7:30 A.M., and Ziprasidone was scheduled for 6:00 A.M. and 8:00 P.M., not aligning with meal times. Additionally, there were multiple missed doses of Ziprasidone, and the DON confirmed the medications were not scheduled at appropriate times, with no clear reason for the missed doses. The consultant pharmacist confirmed that improper timing and missed doses could impact the effectiveness of these medications. Further, during an observation of medication administration, an LPN administered Basaglar Kwikpen insulin and Admelog (Lispro) insulin without priming the insulin pens as required by manufacturer instructions. The LPN confirmed not priming the pens, stating a belief that priming was unnecessary. The DON confirmed that the expectation was for nurses to prime insulin pens prior to administration. Facility policy referenced following manufacturer guidelines, which explicitly require priming the pens to ensure proper dosing. These actions resulted in the resident not being free from significant medication errors, as required.