Failure to Prevent Significant Medication Errors and Ensure Proper Physician Notification
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by multiple incidents involving two residents. In one case, a nurse administered 10 units of fast-acting insulin instead of the scheduled long-acting insulin to a resident. Following this error, blood sugar monitoring was not performed at the 15-minute intervals as ordered, and there was no physician order documented for this monitoring in the medical record. The Assistant Director of Nursing acknowledged the failure to document the order and confirmed that blood sugars were not monitored as frequently as required. Additionally, on a separate occasion, the same resident had their scheduled long-acting insulin withheld due to low blood sugar without evidence of physician notification or an order to hold the medication, contrary to facility expectations. In another incident, a resident with a prescription for Oxycodone 15mg every 8 hours had their order changed to Oxycodone 5mg every 6 hours as needed. Despite this change, the resident was administered the higher 15mg dose on two occasions after the new order was in effect. The medication administration record did not support the administration of the 5mg dose, and the controlled drug record confirmed the dispensing of the 15mg tablets. The Director of Nursing verified that the resident received the incorrect dose, indicating a failure to administer medications as ordered.