Failure to Report Serious Medication Error Resulting in Hospitalization
Penalty
Summary
The facility failed to report a significant medication error to the State Survey Agency as required. A resident with liver cirrhosis and stage 3 kidney disease, who was unable to participate in their assessment, ingested a 10 mg tablet of Zyprexa that was not prescribed to them while receiving medications at the medication cart. The resident subsequently became unresponsive and began to mumble incoherently, prompting the nurse to notify the physician, who ordered a transfer to the emergency room. The resident was hospitalized and required ventilator support in the intensive care unit for three days. The facility's incident log confirmed the event and documented that the state hotline was not notified. During interviews, the Interim DNS stated that regional staff advised the incident did not require reporting, so it was not reported. A newly appointed Interim DNS later stated that the medication error should have been reported, and the CEO was unaware of the incident. The failure to report the serious medication error delayed appropriate oversight and investigation.