Failure to Administer Medications as Ordered Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed for a resident with multiple complex medical conditions, including chronic non-pressure ulcer, peripheral vascular disease, and cerebral infarction. Upon admission from the hospital, the resident had specific orders for Acetaminophen, Gabapentin, and Oxycodone, with detailed dosing schedules and indications for use. However, review of the medication administration records revealed discrepancies between the hospital discharge orders and the facility's transcription and administration of these medications. For example, Acetaminophen was administered more frequently than every 8 hours as ordered, and there were multiple, conflicting Gabapentin orders active at the same time, leading to confusion about the correct dosage and schedule. The resident, who had significant cognitive impairment and required daily administration of opioids, antiplatelets, and anticonvulsants, experienced a decline in condition during their stay. On one occasion, the resident was found to be non-responsive to commands, prompting assessment by a CNP and subsequent transfer to the emergency room. Hospital documentation indicated the resident was drowsy and had received pain medication earlier in the day, with Narcan administered for improvement. Interviews with facility staff, including the DON, confirmed that the medications were not transcribed or administered according to the hospital's orders, particularly regarding the timing and dosage of Acetaminophen and Gabapentin. Facility policy required medications to be administered in accordance with physician orders, including specified time frames, and for staff to consult with a physician if a dosage appeared inappropriate. Despite this, the facility did not ensure accurate transcription or administration of the resident's medications, resulting in significant medication errors. The deficiency was identified during a review of medical records, staff interviews, and hospital paperwork, and was confirmed by the DON.