Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by incidents involving two residents. For one resident with diagnoses of anxiety, depression, and a history of falls, a physician order required lorazepam 0.5 mg to be administered three times daily. On one occasion, the resident received lorazepam twice in the morning—once at 7:00 a.m. and again at 10:00 a.m.—due to miscommunication and lack of proper documentation between LPNs on different shifts. The narcotic log and witness statements revealed confusion regarding whether the medication had been administered, with one nurse unsure if she had given the dose and another not noticing the duplication until the end of her shift. There was also a lack of documentation in the electronic medical record and no report from the midnight shift nurse regarding unscheduled or PRN medication administration. Another resident with depression, anxiety, and chronic pain had physician orders for chlordiazepoxide 10 mg in the morning and 5 mg at bedtime. On two consecutive days, the resident was given 10 mg at bedtime instead of the prescribed 5 mg. This error was identified after a review of the medication administration records, and both the CRNP and the resident's representative were notified. In both cases, the residents did not exhibit adverse effects from the medication errors. The Nursing Home Administrator confirmed that the facility did not ensure residents were free from significant medication errors for these two residents.