Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
Facility staff failed to ensure that three residents were free from significant medication errors, as evidenced by multiple instances where prescribed medications were not administered according to physician orders. For one resident with a history of stroke, heart failure, and pneumonia, medications including Levoquin, Umeclidinium-Vilanterol, and dexamethasone were documented as unavailable on several occasions. Despite the presence of alternative medications in the Omnicell and a facility policy requiring physician notification and alternative therapy consideration, there was no documentation that the physician was notified or that alternative medications were considered or administered. Another resident with Parkinson's disease, diabetes, and a history of CVA did not receive Eliquis, Carbidopa-Levodopa, and sertraline as ordered. The clinical record showed repeated notations of medications being on order or awaiting pharmacy delivery, even though some of these medications were available in the Omnicell. There was no evidence that the physician was notified about the unavailability of these medications, nor was there documentation of any action taken to address the missed doses as required by facility policy. A third resident with multiple chronic conditions, including COPD, diabetes, and vascular dementia, also experienced missed doses of several medications such as Dapagliflozin, Incruse Ellipta, Buspar, and Ipratropium. Medication administration records and nurses' notes repeatedly indicated that medications were not available, on order, or delayed due to insurance issues, with no evidence that the medical provider was notified in a timely manner. Interviews with nursing staff revealed inconsistent understanding of the procedures to follow when medications were unavailable, and the Interim Director of Nursing acknowledged that some residents were not entered into the pharmacy's automatic refill program, contributing to the medication errors.