Failure to Prevent Significant Medication Errors Following Hospital Readmission
Penalty
Summary
The facility failed to ensure that a resident remained free from significant medication errors during and after a hospitalization for hyperglycemia. Upon the resident's return from the hospital, staff did not properly reconcile the medication list, resulting in the administration of two long-acting insulins (Tresiba and Lantus) and an incorrect dose of metformin. The hospital discharge summary specified that the resident should receive Lantus 20 units daily and metformin 500 mg twice daily, but the facility staff administered both Lantus and Tresiba, as well as 1000 mg of metformin instead of the prescribed 500 mg dose. The resident, who had a severe cognitive deficit and required assistance with daily activities, was unable to understand or communicate her diabetes diagnosis and symptoms. Staff failed to clarify duplicate insulin orders with the provider, despite recognizing that both insulins were long-acting and that the resident had not previously been on insulin before hospitalization. The error was compounded by a lack of communication and verification among nursing staff, with the LPN administering both insulins after discussing the orders with the ADON, who advised consulting the DON. The DON did not provide clarification before the medications were given, and the error was only discovered after the resident exhibited symptoms of hypoglycemia. As a result of these medication errors, the resident experienced multiple episodes of low blood glucose, including readings as low as 35 mg/dL, and required emergency interventions such as administration of glucagon and transfer to the hospital. The facility's policies required staff to clarify any conflicting or questionable orders with the physician and to immediately remove discontinued medications from the medication cart, but these procedures were not followed, directly leading to the significant medication errors and the resident's subsequent hospitalization.