Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of medications at incorrect times and the omission of prescribed medications and treatments for all five sampled residents. For example, one resident with multiple sclerosis, sepsis, and osteomyelitis did not receive several medications, such as Tramadol, Vancomycin, and Ciprofloxacin, at the times ordered by the provider. Additionally, this resident missed multiple wound care treatments, skin inspections, hygiene care, weight monitoring, and other essential interventions as documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Another resident with an intracranial injury and paraplegia experienced omissions in the administration of catheter care, wound care, and education regarding anticoagulant therapy. Similarly, a resident with Parkinson's disease and a catatonic disorder did not receive several prescribed treatments, including hand splint application, edema monitoring, pain assessments, and specialty mattress checks. These omissions were consistently documented as blank spaces on the MAR and TAR, indicating that the tasks were incomplete or not performed. Further review revealed that residents with complex medical needs, such as those with multiple sclerosis, respiratory failure, hemiplegia, sepsis, and cellulitis, also experienced missed medication doses and treatments. These included failures to administer pain medications, perform wound care, monitor vital signs, and provide behavioral and psychotropic medication monitoring. Staff interviews confirmed that blank spaces on the MAR and TAR signified missed tasks or medications, and that the facility's policy allowed for a specific window of time for medication administration, which was not adhered to in these cases.