Significant Medication Errors Affect Multiple Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by three separate incidents involving three different residents. In one case, a resident with multiple complex diagnoses, including cerebrovascular disease, chronic kidney disease, and terminal status under hospice care, was administered morphine sulfate at a dosage ten times higher than ordered. The nurse responsible used a medication cup instead of a syringe, resulting in the administration of 2.5 ml instead of the prescribed 0.25 ml for three doses. This error was discovered during a narcotic count discrepancy, and the nurse admitted to the incorrect measurement method. Interviews with facility leadership and medical staff confirmed the error, though it was unclear if the overdose contributed to the resident's subsequent decline and death, as the resident was already in a terminal state. In another incident, a resident reported that she and her roommate were given each other's medications by the assigned nurse. The resident received three Tylenol tablets and one Gabapentin tablet intended for her roommate, while her roommate received her medications. The resident did not experience any negative effects but found the situation concerning. Review of physician orders and interviews with the DON and the nurse involved confirmed that the medication mix-up occurred during a medication pass when the nurse became distracted. The nurse did not notify the provider about the error, rationalizing that the resident had a PRN order for Tylenol. A third resident also reported receiving her roommate's medications, including Midodrine, Amlodipine, and Gabapentin, while her own medications were given to her roommate. The error was identified when the resident questioned an unfamiliar pill, prompting the nurse to realize the mistake. Documentation and interviews revealed that the incident was not clearly detailed in the incident report, and the medications given were not fully documented. The facility's policies require verification of resident identity, proper documentation, and notification of providers and families in the event of medication errors, but these procedures were not consistently followed in these cases.