Significant Medication Errors Due to Administration and Transcription Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first case, a resident with a history of Type 2 diabetes and a recent upper arm fracture, who was cognitively intact, was mistakenly given Hydralazine 75 mg and Clonidine 0.2 mg, both antihypertensive medications, instead of her prescribed pain medication. This error occurred when the resident approached the nurse during medication preparation for another resident, leading the nurse to inadvertently place the wrong medications in the resident's cup. The resident subsequently experienced hypotension, with a blood pressure reading of 80/52, but did not report symptoms such as dizziness or chest pain at the time of assessment. In the second incident, a resident with severe cognitive impairment, Alzheimer's disease, depression, and a history of upper arm fracture was affected by a medication transcription error. Following a provider's recommendation for a gradual dose reduction of Risperidone from 1 mg to 0.75 mg at bedtime, the nurse entered the new order for 0.75 mg but failed to discontinue the existing 1 mg order in the electronic system. As a result, the resident received a combined nightly dose of 1.75 mg of Risperidone for nearly two weeks before the error was discovered. No adverse effects were documented during this period. Both incidents were confirmed by the Nursing Home Administrator and were determined to be the result of failures to follow professional standards of practice, including the Five Rights of Medication Administration and proper transcription of physician orders. These deficiencies were identified through clinical record review, medication error reports, and staff interviews.