Failure to Complete Post-Medication Error Monitoring
Penalty
Summary
A resident with multiple diagnoses, including Parkinson's disease, Alzheimer's disease, dementia, irritable bowel syndrome with constipation, hypertension, obstructive sleep apnea, and spinal stenosis, was involved in a medication error where they were administered Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg in error. Following this incident, the provider issued an order for the resident to be monitored every 4 hours for the next 24 hours, including vital signs and a head-to-toe assessment. Record review revealed that only one assessment was documented during the required monitoring period, with no evidence of additional assessments or vital sign checks every 4 hours as ordered. During an interview, the Director of Nursing confirmed that the nursing staff did not complete the required monitoring and assessments according to the provider's order after the medication error.