Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors, as evidenced by missed and improperly administered medications. One resident with a history of Crohn's disease, chronic pain, and other related conditions was prescribed Gattex for short bowel syndrome. Despite physician orders and care plan interventions to provide medications as ordered, the resident received the medication inconsistently over several months. Documentation on the Medication Administration Record (MAR) indicated that the medication was often marked as unavailable or not given, with progress notes confirming that Gattex was either on order or not accessible to nursing staff. Interviews revealed that the medication was present in the facility but locked in a provider office, leading to miscommunication and failure to administer the drug as prescribed. Another resident, admitted with diagnoses including altered mental status and infection due to a central venous catheter, was prescribed amoxicillin-potassium clavulanate for a bacterial infection. The resident did not receive all ordered doses of the antibiotic, with the MAR and pharmacy records confirming that several doses were missed due to delays in pharmacy delivery and issues with medication removal from the facility's medication dispensary. Staff and pharmacy interviews corroborated that only a portion of the prescribed antibiotics were administered, and the resident ultimately received fewer doses than ordered. The facility's medication administration policy required medications to be administered within a specific time frame and properly documented. However, in both cases, the facility failed to follow these procedures, resulting in significant medication errors for two residents. These findings were confirmed through record reviews, staff interviews, and pharmacy documentation.