Failure to Prevent Significant Medication Errors in TPN Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of the incorrect Total Parenteral Nutrition (TPN) to a resident. The resident, who had diagnoses including peritoneal abscess, colitis, and high blood pressure, was prescribed a specific TPN regimen to be administered over a twelve-hour cycle. On the date in question, the resident received the wrong TPN, which was discovered an hour later when another resident was to have their TPN prepared. The infusion was stopped and the provider was notified. Interviews with staff confirmed that the wrong TPN was administered and that the infusion pump had been set at an incorrect rate, resulting in the resident not receiving the complete dose of TPN. Further review revealed that the TPN products were stored in dedicated, labeled bins for each resident, but a staff member confirmed mixing the incorrect TPN. The Assistant Director of Nursing and the Nursing Home Administrator acknowledged that the facility failed to prevent significant medication errors for two of three residents reviewed. The resident involved reported no ill effects or concerns with the TPN infusions at the time of interview.