Failure to Notify Family of Medication Error and Condition Change
Penalty
Summary
The facility failed to notify the family member or representative of a resident after a significant medication error occurred. According to clinical record review and interviews, a resident was mistakenly administered medications intended for another resident, including Melatonin, Mirtazapine, Alprazolam, and Apixaban. The error was documented as a late entry in the progress notes, and the family was not directly informed by the facility until several days later. Instead, the family learned of the incident through the hospital's History and Physical report, rather than from facility staff. Interviews with the resident's family confirmed that they were not notified by the facility about the administration of the four incorrect medications. The facility's policy and the LPN's job description both require immediate notification of the resident, physician, and family or legal representative in the event of a significant change in condition or medication error. Despite this, the facility only informed the hospital about one of the medications and delayed direct communication with the family, failing to follow established procedures for notification.