Failure to Prevent Significant Medication Errors Due to System and Supply Issues
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two residents not receiving their prescribed medications as ordered. For one resident with a diagnosis of unspecified convulsions and a risk for seizures, two critical seizure medications, Lamictal and Levetiracetam, were not administered as scheduled due to the facility's internet being down. Documentation on the Medication Administration Record (MAR) indicated the medications were not given, with the reason cited as 'no internet.' Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that missing a medication dose for this reason is considered a medication error, and that alternative methods for accessing the MAR, such as making paper copies or using management's cell phone hotspots, were not effectively communicated or implemented at the time of the incident. Another resident, admitted with multiple complex diagnoses including metabolic encephalopathy, sepsis, acute respiratory failure, type 2 diabetes, epilepsy, hypertension, kidney transplant status, and hypothyroidism, did not receive several ordered medications over multiple days. These included anticonvulsants (Lacosamide and Levetiracetam), insulin, and an immunosuppressant (Mycophenolate). The MAR showed multiple instances where medications were not administered, with reasons such as 'drug/item unavailable' or left blank, indicating omission. The DON confirmed that these omissions were medication errors and that staff should have accessed contingency medication supplies, which were available for at least some of the missed medications. Facility policies required medications to be administered in accordance with prescriber orders and within specified timeframes, and mandated that medication errors be documented and reported. The events described show that these policies were not followed, resulting in significant medication errors for both residents. The failures included lack of timely administration, inadequate communication of contingency procedures, and failure to utilize available medication supplies.