Failure to Maintain Emergency Medication Supply and Timely Medication Administration
Penalty
Summary
The facility failed to maintain an on-hand supply of emergency hypoglycemic medication and did not administer anti-seizure medications according to provider orders for two residents. One resident with end stage kidney disease and Type I diabetes experienced multiple episodes of severe hypoglycemia, resulting in unresponsiveness and repeated hospitalizations. Despite standing physician orders for glucagon injections in cases of low blood glucose, the facility did not have glucagon available in the emergency kit or on medication carts. Staff confirmed the absence of glucagon, and documentation showed that during several hypoglycemic events, no glucagon was administered, and the resident was instead sent to the hospital for treatment. Another resident with quadriplegia and a traumatic brain injury did not receive anti-seizure and muscle relaxant medications at the times ordered. Medication administration records showed that doses of Baclofen, Levetiracetam, and Klonopin were given several hours late and in close proximity to each other, rather than being spaced out as prescribed. Staff involved in medication administration were unsure of the policy for late medications and did not contact the provider when errors occurred. There was no documentation in the resident's chart indicating that the provider was notified of the medication errors or that any alert charting was completed. Interviews with staff and review of records confirmed that the facility did not follow standing orders for diabetic management and failed to maintain sufficient emergency medication supplies. Additionally, the facility did not ensure timely and appropriate administration of anti-seizure medications, nor did staff seek guidance from the provider when medication errors occurred. These failures resulted in repeated hospitalizations and placed residents at risk for adverse health outcomes.