Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that two out of three residents were free from significant medication errors. In one instance, a Certified Medication Aide (CMA) administered the correct physician-prescribed medications to a resident, but later, due to interruptions including a phone call and a resident's pressure alarm, the CMA mistakenly gave the same resident medications that were prescribed for another resident. The medications erroneously administered included Melatonin, Mirtazapine, Alprazolam, and Apixaban, which were not intended for the resident who received them. This error was confirmed by a review of video footage, clinical records, and a written statement from the Director of Nursing (DON). In another case, a resident continued to receive both Seroquel 12.5 mg and Seroquel 25 mg in the morning, despite a physician's order changing the regimen to Seroquel 25 mg in the morning and 12.5 mg at noon and supper. This discrepancy was discovered during staff rounds, indicating that the medication order change was not properly implemented, resulting in the resident receiving an incorrect dosage for an extended period.