Significant Medication Errors Due to Omission and Documentation Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the omission and improper administration of critical medications for two residents. For one resident, Metoprolol and Entresto, both prescribed for hypertension and heart failure, were not administered as ordered on a specific evening. Additionally, upon admission from the hospital, Entresto was not ordered for another resident, despite it being listed on the hospital discharge medication list. This omission was not identified or corrected by the admitting nurse or subsequent staff responsible for medication reconciliation and order entry. The same resident also failed to receive Eliquis, an anticoagulant prescribed for atrial flutter, on eight occasions in a single month. The medication administration record (MAR) showed multiple blanks with no documentation to indicate whether the medication was given or refused. Interviews with nursing staff revealed inconsistent documentation practices, with some staff admitting to forgetting to chart medication administration or not following up on missed doses. There was also a lack of clarity and communication regarding the process for documenting refusals and ensuring that all medications were administered as ordered. The resident who missed multiple doses of Eliquis was later hospitalized and diagnosed with atrial fibrillation with rapid ventricular response, acute on chronic systolic and diastolic heart failure, and a small pulmonary embolus. Staff interviews indicated that the resident was sometimes noncompliant or refused medications, but there was no consistent documentation of refusals or evidence that appropriate notifications were made to the physician or family. The facility's policies required that all medication refusals or omissions be documented in the MAR, but this was not consistently followed, leading to significant medication errors.
Removal Plan
- The administrative nursing team (Director of Nursing, Assistant Director of Nursing and MDS Coordinator) with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations will complete medication order reviews for all residents admitted and re-admitted to ensure no residents are in jeopardy or threat of harm.
- Chart reviews of the remaining residents admitted and re-admitted will be completed by the administrative nursing team with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations to ensure accurate reconciliation of hospital discharge orders/admitting orders to those that were verified with the attending physician and transcribed into the electronic health record.
- Chart reviews will ensure all diagnosis/health conditions of residents is being/has been addressed/noted in the electronic health record.
- The Facility Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator were counseled and provided with an in-service by the Director of Clinical Operations and the Assistant Director of Clinical Operations regarding daily review of admission records, admission order reconciliation, review of 24/72 hour report, and reviewing the missing medication report each morning during the morning meeting process.
- The Facility Administrator will be responsible for ensuring the daily review of the missed medication report, admission record review, admission order reconciliation, and review of the 24/72-hour report. In the absence of the Facility Administrator the Director of Nursing will be responsible.
- All nurses and certified medication aides present at the time of the notification will be provided with in-service training regarding the admission/re-admission process, the admission/readmission medication reconciliation process, transcribing and carrying out physician orders, how to document different scenarios of medications not given (refused, spit out, held for vital signs outside of parameters, etc.), checking the dashboard throughout and at the end of their shift to ensure no medication documentation is missing.
- The staff in-service will be conducted by the Administrative Nursing Team and will continue until all nurses and certified medication aides have been provided with the beforementioned education; the remaining nurses and certified medication aides will be educated prior to beginning their next shift.
- All newly hired nurses and certified medication aides will be educated regarding how to document missed doses, refused doses, and accessing the dashboard to ensure all doses are accounted for before the end of their shift before beginning their first assigned shift.
- A QAPI meeting was conducted with the Medical Director, Facility Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Corporate Director of Clinical Operations, and Assistant Corporate Director of Clinical Operations. The root cause analysis of the alleged deficient practice was reviewed and interventions to correct and prevent future occurrence were discussed.
- The Consultant Pharmacist was contacted by the Corporate Director of Clinical Operations and discussed the alleged deficient practice; it was decided that all new and re-admissions to the facility will be reviewed by a pharmacist with the consultant pharmacy group every Monday, Wednesday and Friday.
- The Consultant Pharmacist will review all residents admitted /re-admitted to the facility. In addition to the regular medication regimen review the consulting pharmacist will reconcile current physician orders to those given from the discharging entity. Upon completion of his/her review, the consulting pharmacist will provide a summary of findings/recommendations to the Director of Nursing, Assistant Director of Nursing and Facility Administrator. Immediately upon receipt of the recommendations the Director of Nursing will ensure any physician recommendations are addressed and carried out.
- The recommendations from the consultant pharmacist will be reviewed during the morning meeting Monday through Friday and the Facility Administrator and Director of Nursing will verify they are complete with a physician acceptance or declination, orders corrected or changed as recommended/agreed to by physician, plan of care updated, and resident/resident representative informed of changes.
- The Corporate Director of Clinical Operations will provide an in-service to the Facility Administrator and administrative nursing staff regarding the review of the pharmacy consultant admission/re-admission drug regimen review/medication reconciliation process that is to be reviewed during the morning meeting every Monday through Friday.
- The facility nursing administration staff (Director of Nursing, Assistant Director of Nursing, and MDS Nurse) with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations will begin a full audit of all resident medication orders.