Significant Medication Administration Errors Identified
Penalty
Summary
Facility staff failed to administer medications as ordered for two residents, resulting in significant medication errors. For one resident with a history of infection and inflammation of a hip prosthesis, COPD, alcoholic cirrhosis with ascites, and hypertension, hospital discharge orders specified Levaquin 750 mg once daily by mouth. However, the medication was administered twice daily over a four-day period, contrary to the prescriber's instructions. This discrepancy was confirmed through medical record review and staff interview. Another resident, admitted with nontraumatic subarachnoid hemorrhage, atrial fibrillation, and COPD, had hospital discharge orders to hold Eliquis 5 mg until a specified date and to administer cefuroxime 500 mg twice daily for three days. Despite these orders, Eliquis was administered on days it should have been held, and cefuroxime was not signed off as administered. These findings were corroborated by review of the medication administration records and confirmed in an interview with the Administrator. The facility's policy requires medications to be administered according to prescriber orders, including timing, which was not followed in these cases.