Failure to Notify Physician and Monitor Resident After Medication Errors
Penalty
Summary
The facility failed to notify the physician in a timely manner and did not monitor a resident for adverse effects after medication errors occurred. Specifically, a resident with diagnoses including type 2 diabetes mellitus, diabetic neuropathy, and Alzheimer's disease missed scheduled doses of insulin and other medications on two separate occasions. On both occasions, the medication errors were not promptly identified by nursing staff, and the resident's physician was not notified as required. Additionally, there was no evidence in the medical record that the resident was monitored for adverse effects following the missed doses, despite facility policy requiring monitoring for 24 to 72 hours after a medication error. The resident involved was cognitively impaired, unable to complete mental status interviews, and dependent on staff for medication administration. The errors included missed doses of insulin, allergy medication, neuropathy medication, blood pressure medication, pain medication, and others, as well as missed blood glucose monitoring. The Director of Nursing confirmed that the required monitoring and physician notification did not occur after the medication errors, which was inconsistent with the facility's own policy on managing medication errors.