Failure to Administer Medications as Ordered Due to Unavailable Medication and Incomplete Error Reporting
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by physicians for two residents, resulting in significant medication errors. For one resident with a diagnosis of radiculopathy, a 30-day supply of Gabapentin was delivered, but 49 capsules went missing and the facility could not determine when or how they disappeared. As a result, the resident missed multiple scheduled doses of Gabapentin over several days. Although Gabapentin was available in the facility’s Emergency Kit (E-Kit), nursing staff and a qualified medication aide did not check the E-Kit and assumed the medication was unavailable, leading to further missed doses. Documentation confirmed that the pharmacy had delivered replacement Gabapentin to the E-Kit, but staff failed to utilize it, and the missed administrations were acknowledged as medication errors by the Director of Nursing (DON). Another resident, who had a history of traumatic brain injury, cognitive impairment, and other complex medical conditions, did not receive ordered monthly Depo-Provera injections on several occasions because the medication was not available. Progress notes indicated repeated instances where the medication was not available and orders were sent to the pharmacy, but there was no documentation of administration for multiple months. Medication error reports were completed for some missed doses, but not for all, and the DON confirmed that the facility did not follow its own policy for documenting and reporting all medication errors related to these missed injections. Interviews with staff revealed that the medication reordering process relied on reminders and manual reordering through the electronic medical record system, but lapses in communication and follow-through led to medication shortages and missed doses. The DON reviewed progress notes daily but did not identify all missed doses or ensure that medication error reports were completed as required by facility policy. The facility’s policy required documentation, investigation, and reporting of all medication errors, but these procedures were not consistently followed, resulting in unaddressed medication errors for both residents.