Failure to Prevent Significant Medication Errors and Ensure Timely Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by multiple instances where scheduled medications were not administered at the prescribed times or were omitted entirely. The resident, who had a history of left below the knee amputation, spinal stenosis, anxiety, and depression, was observed to be visibly uncomfortable, pale, and anxious while waiting for her morning medications, which were administered over three hours late. On several occasions, documentation was missing regarding the reasons for late or omitted medication administration, and there was no record of the resident's condition at those times. Staff interviews revealed uncertainty about whether medications were given late or simply not documented, and there was no evidence that the physician or other staff were notified of these errors. The resident's Medication Administration Record showed repeated late administration of critical medications, including pain management drugs and antihypertensives, as well as missed doses of Pregabalin. The facility's policy required assessment, documentation, and notification in the event of medication errors, but these procedures were not followed. Staff could not provide clear explanations for the discrepancies, and there was no documentation of monitoring or interventions in response to the errors. The lack of adherence to medication administration protocols resulted in the resident experiencing discomfort and anxiety.