Failure to Implement QAPI Following Medication Error
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) plan after being made aware of a medication error involving a resident who was admitted from a general acute care hospital. The registered nurse did not thoroughly review or clarify conflicting discharge instructions regarding the administration of Baclofen, a medication known to cause confusion, before transcribing and administering it. Specifically, the nurse did not verify the hospital's orders with the attending physician, despite discrepancies in the discharge instructions—one indicating Baclofen should not be used due to confusion, and another listing it as a medication to continue. As a result, the resident received multiple doses of Baclofen without proper clarification. This error led to the resident experiencing shortness of breath, elevated blood pressure, generalized weakness, and increased confusion, ultimately resulting in a transfer back to the hospital where the resident was diagnosed with acute toxic encephalopathy and required dialysis. Interviews with facility leadership revealed that no incident report was filed, and no QAPI meeting was conducted to address the medication error, investigate the root cause, or implement corrective actions as required by the facility's own policies and procedures.