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 the care of two residents. For one resident with chronic kidney disease, a physician's order for Aranesp 25 mcg every 7 days was not entered into the resident's record upon admission, and subsequent medication administration records showed that the medication was not given on multiple ordered dates. Laboratory results indicated that the resident's hemoglobin levels were within the range that required administration of Aranesp, yet there was no evidence that the medication was provided as ordered. Additionally, there was no documentation that the provider was notified of these missed doses, and the physician confirmed he was not informed of the missed administrations. Another resident admitted with dementia and vertebral fractures had physician's orders for Heparin and Trazodone, but the medication administration record did not show evidence that these medications were given on the day of admission. Again, there was no documentation that the provider was notified of the missed medication administrations. The Director of Nursing Services confirmed that it was her expectation that physician's orders should have been followed and was unable to provide evidence that the residents were kept free from significant medication errors.