Failure to Prevent Significant Medication Errors in Scheduled Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of potassium chloride at incorrect times for two residents. For one resident with diagnoses of atrial fibrillation and chronic kidney disease, physician orders specified potassium chloride to be administered at 10:00 a.m. and 10:00 p.m., and furosemide at 8:00 a.m. However, observations and medication audit reports revealed that potassium chloride was administered outside the prescribed times on multiple occasions, including one instance where the medication was given at 8:44 a.m. instead of the scheduled time, and the administration could not be properly documented in the electronic medical record due to timing restrictions. Additional audit findings showed repeated late administrations over several days. Another resident with dementia and a thyroid disorder also had orders for potassium chloride at 10:00 a.m. and furosemide at 8:00 a.m. Medication audit reports indicated that these medications were frequently administered and documented at times inconsistent with the physician's orders, with doses given significantly earlier or later than scheduled. Interviews with the DON and Nursing Home Administrator confirmed that the facility did not ensure residents were free from significant medication errors, as required by facility policy and state regulations.