Failure to Prevent Significant Medication Errors
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors, as evidenced by multiple incidents involving incorrect medication administration. On one occasion, fluorouracil 5% cream, prescribed for application to a skin cancer lesion on the chest, was instead applied to the resident's neck. This resulted in redness and a burning sensation, requiring subsequent treatment with hydrocortisone. The error was confirmed by both the resident and the LPN involved, and the pharmacist explained that the medication should only be applied to the specific lesion due to its cell-killing properties. Additionally, there were three separate incidents where Debrox ear drops were administered into the resident's eye instead of the ear. Each time, the resident experienced burning and discomfort, and the errors were documented in facility reports. The pharmacist clarified that Debrox is intended solely for ear use and can cause significant irritation if placed in the eye. The reports indicated that the errors occurred due to confusion between medication containers and a failure to properly check medication labels before administration. A further deficiency was identified when Baclofen, a muscle relaxant prescribed for muscle spasms and spinal stenosis, was administered several hours later than scheduled. Facility policy requires medications to be given within one hour of the scheduled time, and both nursing and pharmacy staff confirmed the importance of timely administration for this medication. The resident's clinical record and medication administration audit confirmed the late administration, and staff interviews acknowledged the deviation from protocol.