Failure to Notify Responsible Party After Medication Error
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident when there was a significant change in the resident's condition following a medication error. The resident, who had diagnoses including hemiplegia, hemiparesis, atrial fibrillation, and type 2 diabetes mellitus, was assessed as having moderate cognitive impairment and lacked capacity to make certain decisions. On the day of the incident, the resident was administered multiple medications that were not prescribed for him by a new nurse who did not verify his identity or review his medications with him. As a result, the resident became unusually sleepy and had low blood pressure, which was first noticed by his RP during a visit. Despite facility policy requiring immediate notification of the resident and responsible party in the event of a medication error or significant change of condition, the assigned LVN did not inform the RP after being instructed to do so by the DON. The LVN stated she was focused on monitoring the resident and forgot to call the RP. The RP only learned of the medication error when the DON entered the room later that day. Facility records and staff interviews confirmed that the required notification was not made in a timely manner, contrary to facility policy.