Failure to Provide Timely Assessment and Provider Notification After Medication Error
Penalty
Summary
A resident with a history of schizoaffective disorder, chronic obstructive pulmonary disease, urinary tract infection, and chronic pain syndrome was admitted to the facility with specific medication titration orders for clozapine following a recent hospital stay. The hospital discharge instructions required a gradual titration of clozapine, starting at a low dose and increasing incrementally. However, the resident was mistakenly administered a 100mg dose of clozapine instead of the prescribed 12.5mg, constituting a medication error. Following the medication error, the resident exhibited significant changes in condition, including excessive sleepiness, difficulty staying awake, inability to use an inhaler, elevated blood pressure and heart rate, decreased oxygen saturation, and later, confusion and garbled speech. Despite these clear signs of a change in condition, the facility failed to conduct comprehensive RN assessments or provide detailed documentation of the resident's status. There was also a lack of timely and appropriate notification to the resident's provider, as required by facility policy and professional standards of nursing practice. The resident experienced a fall, continued to display altered mental status, and eventually required emergency transfer to the hospital, where an accidental overdose of clozapine was confirmed. Interviews with facility leadership and the nurse practitioner revealed that expected monitoring and provider communication did not occur, and documentation of assessments was lacking. The facility did not follow its own policy for change in condition, failed to notify the provider promptly, and did not ensure ongoing comprehensive assessments after the medication error.