Significant Medication Errors Due to Dosage, Communication, and Documentation Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving two residents. For one resident with multiple sclerosis, anxiety disorder, and legal blindness, the physician's order for Ativan was reduced from two tablets to one tablet at bedtime. Despite this change, the controlled substance administration records showed that the resident continued to receive two tablets on several occasions, as the medication label was not updated and still indicated the previous dosage. Nursing staff, including a unit manager, confirmed that double doses were administered on specific dates, and this was acknowledged as a medication error. Another resident with diabetes, end stage renal disease, and a left leg amputation experienced several medication errors related to anemia management and pain control. The resident was prescribed Epoetin alfa weekly, but the medication was not administered on several scheduled dates due to unavailability from the pharmacy, and there was no evidence that the physician was notified of the missed doses. Additionally, the resident was receiving Mircera, a similar medication, at an outside dialysis center, but neither the facility nor the dialysis center was aware of the dual prescriptions. Furthermore, the resident received Tramadol, an opioid pain medication, at intervals shorter than prescribed, and the administration was not properly documented in the medication administration record. Facility policy required medications to be administered as prescribed, with verification of the correct resident, medication, dosage, time, and method, and for staff to document administration immediately. The observed failures included not updating medication labels, not notifying physicians of missed doses, lack of communication between the facility and dialysis center regarding medication administration, and improper documentation and timing of medication administration.