Medication Administration Errors Result in Missed Doses for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first case, a resident with Parkinson's Disease, who had previously been assessed as unable to self-administer medications due to tremors, did not receive her evening doses of Carbidopa-Levodopa as prescribed. Medications were found on her bedside table and on the floor under her wheelchair, and both the resident and staff confirmed that the evening medications had not been taken. The facility's policy defines omitted medications as a medication error, and staff interviews confirmed that the resident was not supposed to self-administer her medications at this time. In the second case, another resident with a recent surgical procedure and a wound infection did not receive a scheduled dose of intravenous Meropenem, an antibiotic ordered to treat the infection. The medication administration record (MAR) for this resident showed a blank entry for the missed dose, and multiple staff members, including an LPN, the ADON, and the DON, confirmed that a blank on the MAR indicates the medication was not given. There was no documentation to support that the dose was administered as ordered. Both incidents demonstrate a failure to follow physician orders and facility policy regarding medication administration and documentation. The omissions were identified through direct observation, interviews with staff and residents, and review of medical records and facility policies. The facility did not ensure that medications were administered as prescribed or that proper documentation was maintained, resulting in significant medication errors for both residents.