Failure to Prevent Significant Medication Error Resulting in Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to protect residents from significant medication errors, as evidenced by a resident with an active order to have medications crushed receiving their medications whole. This error occurred despite the facility's policies and job descriptions, which require the NHA and DON to ensure compliance with federal, state, and local regulations and to maintain the highest degree of quality care for each resident. The failure to follow the prescribed medication administration led to a critical incident involving the resident. Following the administration of whole medications instead of crushed, the resident experienced a severe adverse event, ceasing to breathe after going into respiratory failure post-aspiration coughing event. The NHA and DON confirmed during interviews that they did not effectively manage the facility to prevent this significant medication error, resulting in an Immediate Jeopardy situation for one of five residents reviewed. The report cites violations of multiple Pennsylvania Codes related to the responsibility of the licensee, management, and nursing services.