Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to prevent significant medication errors for two residents. For one resident with a history of postlaminectomy syndrome, chronic pain, and muscle spasms, the provider changed the order for tizanidine from a routine schedule to as needed (PRN) due to the resident experiencing drowsiness and dizziness after a dose increase. Despite this order being given, the medication continued to be administered on a routine basis for several days before the order was updated, resulting in the resident receiving more medication than prescribed during that period. Another resident with Type I Diabetes Mellitus and diabetic polyneuropathy did not receive scheduled blood glucose monitoring or insulin doses for multiple administration times. This occurred because the facility ran out of blood glucose monitoring strips and did not have a backup supply. The staff did not obtain strips from alternative sources, and as a result, the resident's blood glucose was not checked, and insulin was not administered as ordered. When strips became available, the resident's blood glucose was found to be significantly elevated, and an extra dose of insulin was required. Interviews with facility staff and the nurse practitioner confirmed the sequence of events, including the delay in updating medication orders and the lack of timely action to secure necessary supplies for blood glucose monitoring. Documentation in the medical records and medication administration records supported these findings, showing missed doses and lack of provider notification regarding the missed monitoring and medication administration.