Failure to Promptly Notify Physician and POA After Medication Error
Penalty
Summary
A medication error occurred involving a resident with diabetes and hypertension, who was prescribed both long-acting and rapid-acting insulin. On the evening in question, the resident received 30 units of insulin, but the nurse administering the medication was interrupted multiple times and later could not recall which type of insulin was given. The resident subsequently experienced a significant drop in blood glucose levels, requiring close monitoring and intervention throughout the night. Documentation shows that the resident was alert and oriented during the incident, and her blood sugar was stabilized after several checks and interventions. Despite the seriousness of the medication error and the resident's change in condition, the facility failed to promptly notify the resident's physician and the resident's Power of Attorney (POA) at the time the error was discovered. The physician was not informed until the following morning during office hours, and the POA only learned of the incident after being contacted by the resident herself later that morning. Interviews with facility staff confirmed that the notifications were not made immediately upon discovery of the error, contrary to facility policy and standard practice. Facility policies require prompt notification of the attending physician and the resident's representative in the event of significant medication errors or changes in condition. The failure to notify both the physician and the POA in a timely manner was confirmed through interviews, record review, and statements from those involved. The deficiency centers on the lack of immediate communication regarding the medication error and the resident's subsequent hypoglycemic episode.