Medication Administration Errors Involving Multiple Residents
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by incidents involving three residents. For one resident with atrial fibrillation, anxiety, and depression, a nurse administered oxybutynin chloride 5 mg to the wrong resident by pre-pouring medications for two roommates and giving the medication cup intended for one resident to the other. The error was identified when the resident who received the wrong medication noticed the name on the cup was not theirs, and the nurse confirmed the mistake. In another incident, the same resident was prescribed Spiriva 10 mcg via inhalation, but a nurse administered the medication orally instead of through the inhaler. The resident questioned the unfamiliar pill but was told by the nurse that it was the correct medication in oral form. The nurse later confirmed that the medication was given by mouth rather than inhaled, contrary to the physician's order. A third resident with epilepsy was affected when their seizure medications, Keppra and Lacosamide, were not administered as ordered. The error occurred due to a software default when a registered nurse entered the physician's orders into the electronic medical record, causing the medications to be scheduled to start a day later than intended. As a result, the resident missed doses of both medications. These incidents were confirmed through review of clinical records, facility documentation, and staff interviews.