Failure to Prevent Significant Medication Errors and Ensure Proper Medication Administration
Penalty
Summary
The facility failed to prevent significant medication errors for two residents, resulting in one resident being administered another resident's medications and requiring hospital transfer due to an accidental overdose. One resident with a history of stroke, diabetes, bipolar disorder, chronic kidney disease, and seizures was given medications intended for another resident, including blood pressure and psychiatric medications. The error occurred when a unit manager, after being notified by a CNA of pills found in the resident's food, separated the pills and administered them without verifying their origin. It was later discovered that these medications belonged to another resident who sat beside the affected resident in the dining room. The error was not immediately communicated to the physician, and the resident was not continually assessed as required by facility policy. The resident subsequently experienced a significant change in condition, including hypotension and disorientation, leading to a code blue and emergency transfer to the hospital. The facility's policies required that the person who prepares the medication dose must be the one to administer it, and that in the event of a medication error, immediate steps must be taken, including contacting Poison Control, notifying the primary care provider, and initiating post-error monitoring. In this incident, these steps were not followed. The physician was not promptly notified, Poison Control was not contacted while the resident was still in the facility, and the family was not informed until after the resident was sent to the emergency department. Interviews with staff revealed confusion about communication protocols and a lack of immediate action following the discovery of the error. A second medication error involved another resident who did not receive their prescribed nebulizer treatments as ordered. Instead, an LPN used another resident's medication to administer a nebulizer treatment and left the medication at the bedside, contrary to policy. The LPN did not verify the availability of the correct medication, failed to ensure the resident received the full dose, and missed a scheduled dose. The errors were discovered after the resident reported not receiving treatments, and subsequent interviews confirmed that medications were not administered as ordered and were not properly supervised.