Failure to Administer Medications per Physician Orders Resulting in Significant Medication Errors
Penalty
Summary
A deficiency occurred when staff failed to administer medications according to physician orders for a resident with chronic kidney disease, generalized anxiety disorder, major depressive disorder, and primary insomnia. The resident required substantial assistance with mobility and was dependent on staff for transfers and toileting. The care plan and medication administration record directed staff to administer lorazepam before meals and clonazepam at bedtime for anxiety. However, review of medication records revealed that the resident received an extra dose of lorazepam at bedtime on multiple occasions and missed several doses of clonazepam at night. The medication error was identified when a Certified Medication Aide (CMA) noticed that clonazepam had only been signed out every other night, and further review showed that lorazepam was being given at night instead of clonazepam. Progress notes documented that during this period, the resident experienced increased anxiety, shakiness, insomnia, and reported not feeling well. The resident and her family expressed concerns about her condition, leading to a hospital evaluation where acute insomnia and mood changes were noted. The facility's documentation also showed that on one occasion, a dose of lorazepam was omitted in the afternoon. Interviews with staff confirmed that the CMA confused the two medications and administered them incorrectly. The nurse practitioner indicated that the resident's symptoms of increased anxiety and difficulty sleeping could be related to receiving the shorter-acting lorazepam instead of the longer-acting clonazepam at night. The facility's policy required staff to follow the five rights of medication administration, but this was not adhered to in this case, resulting in significant medication errors for the resident.