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 two residents. In the first case, a resident with a history of epilepsy and anxiety disorder experienced a grand mal seizure and was hospitalized. The family reported that the resident had not received Keppra, an anti-epileptic medication, for several months following a 30-day order after a previous hospital visit. Review of the medication administration records confirmed that Keppra was not administered from mid-May until the resident's hospitalization in August, and facility leadership acknowledged they were unaware of the lapse until notified by the family. There was no documentation of a physician's order to discontinue the medication or any explanation for the omission. In the second case, another resident with dementia, anxiety disorder, and hypothyroidism was administered medications intended for a different resident, including Trazodone, Senna, Zyprexa, and Tramadol. The error was documented in the clinical progress notes, and it was confirmed that the resident did not receive her routine medications at bedtime on the day of the incident. The LPN involved was educated on proper medication administration checks following the event. The resident did not exhibit any acute distress or adverse effects as a result of the error. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed both incidents and acknowledged that the facility failed to prevent significant medication errors for both residents. The facility's own policies require verification of medication orders, resident identification, and administration procedures, which were not followed in these cases. The deficiencies were cited under multiple state regulations regarding licensee responsibility, management, resident care policies, and nursing services.