Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to prevent significant medication errors for two out of five residents reviewed for medication administration. In one instance, a registered nurse administered Insulin Lispro to a resident with diabetes, chronic respiratory failure, and stroke, instead of the intended recipient, after misidentifying the resident. The nurse relied on a certified nursing assistant's identification and did not verify the resident's identity according to the facility's medication administration policy. The error was discovered after the medication was given, and the resident's blood sugar was subsequently monitored. In another case, a registered nurse administered Lorazepam, intended for a different resident, to a resident with Alzheimer's disease and anxiety disorder. The nurse mistakenly pulled the medication from the wrong medication card during a busy and distracting medication pass. The error was realized later during a medication count, and the nurse confirmed the mistake during an interview. Additionally, a licensed practical nurse administered Alprazolam 0.5 mg, intended for another resident, to the same resident with Alzheimer's disease and anxiety disorder, instead of the prescribed 0.25 mg dose. The nurse took the medication from the wrong medication card and only realized the error after the fact. The facility's policy required staff to follow the six rights of medication administration, including verifying the right resident, drug, dosage, route, time, and documentation. However, in these incidents, staff failed to properly verify resident identity and medication details, resulting in the administration of incorrect medications or dosages. There was no documentation of further monitoring or physician orders following the errors, and the Director of Nursing confirmed that no audits or medication administration observations were conducted after the incidents.