Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving eight residents. Errors included administering the wrong medication, incorrect dosages, omission of prescribed medications, and failure to follow physician orders. For example, one resident with dementia and other chronic conditions was given her roommate's opioid pain medication, resulting in increased lethargy and drowsiness that required medical intervention. Another resident with a history of vertebral fractures and cancer did not receive her prescribed narcotic pain medication as requested, leading to untreated and increased pain for several hours. Additional incidents involved residents receiving incorrect doses of medications for chronic conditions such as fibromyalgia, with one resident repeatedly given the wrong dose or missing doses of Lyrica. Another resident with osteomyelitis and kidney failure was administered the wrong intravenous antibiotic. There were also cases where enteral feedings were omitted, a resident received a higher dose of a sleep medication than ordered, and a resident was given a transdermal patch with the wrong dosage of fentanyl, which was not discovered until the following day. Further, a resident receiving end-of-life care was administered another resident's tramadol instead of the prescribed alprazolam for anxiety. These errors were confirmed through record reviews, incident and accident reports, and staff interviews, with the DON verifying the occurrences. The medication errors resulted in actual harm to some residents and had the potential for adverse outcomes for others due to the failure to adhere to the eight rights of medication administration.