Failure to Prevent Significant Medication Errors Due to Missed Doses and Documentation Discrepancies
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by multiple missed doses and discrepancies in medication administration. Medical record review, MARs, pharmacy delivery records, and staff interviews revealed that the resident, who had multiple diagnoses including dementia, atrial fibrillation, diabetes, and other chronic conditions, did not consistently receive prescribed medications such as diltiazem, sotalol, isosorbide, metformin, and oxycodone. There were several instances where medications were not available in the facility, and the MARs contained blank entries or indicated medications were not administered. Additionally, there were discrepancies where the MAR documented administration of medications that were not actually present in the facility, and the DON was unable to explain these inconsistencies. The resident was dependent on staff for medication administration and was cognitively impaired. During the period in question, the resident experienced an episode of altered mental status, abnormal vital signs, diaphoresis, numbness, and vomiting, which led to a transfer to the hospital. The review of progress notes indicated that the physician was not notified of the medication discrepancies, and there was no documentation of physician notification regarding missed or unavailable medications. The facility's own policy required documentation and explanatory notes when medications were withheld or not administered, but this was not consistently followed. Interviews with the DON and the resident's primary care physician confirmed that the facility did not have the required medications on hand during several periods, and the physician was not made aware of these issues. Pharmacy delivery records corroborated the gaps in medication availability, and controlled drug records showed that certain medications, such as oxycodone, were not refilled in a timely manner. The lack of communication and documentation, combined with the failure to ensure medication availability and accurate administration records, directly contributed to the deficiency.