Failure to Immediately Notify Physician and Family After Medication Error
Penalty
Summary
The facility failed to immediately notify a resident's physician and representative after a significant medication error occurred. A registered nurse administered another resident's antipsychotic medications, including Clozaril 200 mg and Geodon 80 mg, to a resident with multiple medical conditions such as type 2 diabetes, dementia, bradycardia, and aortic valve stenosis. The error was identified by another nurse, but neither the resident's physician nor the resident's family was promptly informed of the incident. The resident's spouse was present in the facility visiting the resident after the medication error but was not informed of the incident by staff. The spouse subsequently took the resident out on a leave of absence, during which the resident became unresponsive and required emergency medical services. The family only learned of the medication error when they returned to the facility to obtain documentation for EMS. Interviews with staff confirmed that the nurse responsible for the resident did not notify the physician or the family immediately after discovering the error, waiting instead until after the family returned to the facility. The Director of Nursing and the Administrator were unable to provide evidence that immediate notification had occurred. The resident required emergency transport, hospitalization, and ventilator support as a result of receiving medications not prescribed for them.