Failure to Prevent Significant Medication Error Leading to Resident Harm
Penalty
Summary
A significant medication error occurred when a resident received Hydrocodone-Acetaminophen (Norco) after it had been discontinued following a hospital visit. The discontinuation order was not properly entered into the resident's chart, resulting in the medication remaining active in the facility's records. Subsequently, the resident was administered Norco more frequently than the prescribed interval, with doses given two hours apart instead of the ordered six-hour interval. Documentation of medication administration was inconsistent, with one dose recorded in the narcotic log but not in the electronic medication administration record (eMAR), leading to a double dosing event. The resident involved was an elderly female with multiple complex medical conditions, including hypotension, muscle weakness, type 2 diabetes, end stage renal disease, dependence on dialysis, and chronic embolism and thrombosis. Upon readmission from the hospital, her discharge instructions included discontinuation of Norco, but this was not reflected in the facility's medication orders. The resident exhibited symptoms of lethargy, nausea, vomiting, and decreased responsiveness following the medication error. Staff noted the overdose and monitored the resident, but her condition deteriorated throughout the day, culminating in respiratory distress and eventual cardiac arrest. She was transported to the hospital, where she expired later that evening. Interviews and record reviews revealed lapses in medication reconciliation, documentation, and adherence to physician orders. Staff failed to ensure that discontinued medications were removed from the active medication list and did not consistently document administration in both the eMAR and narcotic log. There was also a lack of timely and effective communication with the physician regarding the resident's change in condition and the medication error. These failures directly contributed to the resident receiving a discontinued medication at an unsafe frequency, resulting in a significant adverse event.