Significant Medication Errors Due to Failure to Follow Provider Orders
Penalty
Summary
Facility staff failed to ensure residents were free from significant medication errors, as evidenced by three separate incidents involving three residents. In one case, a resident with a history of urinary tract infections and severe cognitive impairment was readmitted with a hospital discharge order for IV Ceftriaxone Sodium (Rocephin) to treat an acute UTI. Instead, staff transcribed and administered Ceftazidime, not the ordered medication, and there was a delay in starting the antibiotic, with the first dose given several days after readmission. The resident never received the prescribed Ceftriaxone Sodium. In another instance, staff did not follow provider orders for the administration of Carvedilol, a medication for heart failure and hypertension, for a resident with severe cognitive impairment and multiple cardiac diagnoses. The provider's order specified to hold the medication if the pulse was less than 60, but staff administered Carvedilol on two occasions when the resident's pulse was documented as 59. A third incident involved a resident with paroxysmal atrial fibrillation and multiple myeloma, who was prescribed Metoprolol Tartrate with instructions to hold the medication if systolic blood pressure was less than 110. Staff administered the medication twice when the resident's systolic blood pressure was documented as 109, contrary to the provider's order. These events demonstrate failures in medication transcription, administration, and adherence to provider orders.