Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving three residents. For one resident with a history of traumatic cerebral hemorrhage and severe cognitive impairment, there was a physician order to hold apixaban, an anticoagulant, until cleared by neurosurgery. Despite this, the resident received 21 doses of apixaban due to a miscommunication between the facility, pharmacy, and nursing staff. The medication was dispensed and administered based on an incorrect pharmacy label and a lack of proper verification against the actual physician order, which resulted in the resident receiving the medication prior to neurosurgical clearance. Another resident, who had moderate cognitive impairment and was being treated for nerve pain, experienced a medication error when Lyrica, a prescribed medication, was held for several days without a physician order. This occurred after the pharmacy placed a hold on the medication following a neurology appointment that only called for discontinuation of gabapentin, not Lyrica. Despite attempts by facility staff to clarify the order with the pharmacy, the resident missed nine doses of Lyrica, leading to increased confusion and withdrawal symptoms until the medication was restarted. A third resident, with a diagnosis of congestive heart failure and who was receiving opioid and hypnotic medications, experienced several medication errors. These included administration of a sedative-hypnotic at the wrong time, omission of a scheduled buprenorphine patch change, administration of another resident's medications, and administration of Entresto despite blood pressure readings below the ordered threshold for holding the medication. These errors were confirmed through record review and staff interviews, indicating failures in medication administration, documentation, and adherence to physician orders.