Medication Errors Due to Unavailable and Expired Medications
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication availability and administration practices. One resident with spina bifida, paraplegia, and a stage 4 pressure ulcer did not receive prescribed clotrimazole-betamethasone cream as scheduled because the medication was not available in the facility. Nursing staff were unable to locate the cream in the medication cart or room, and although a paper pharmacy re-order form was completed in the morning, it was not faxed to the pharmacy until late at night. The resident missed multiple scheduled applications of the cream, and there was no clear documentation that the physician was notified of the missed doses, contrary to facility policy. Another resident with dementia and chronic kidney disease was nearly administered an expired multivitamin with minerals. During medication preparation, an LPN placed a tablet from a bottle with an expiration date that had already passed into the resident's medication cup. Upon surveyor inquiry, the LPN removed the expired medication and sought a replacement. The nursing supervisor confirmed that nurses are expected to check expiration dates daily and during monthly cart cleaning, but was unsure which shift was responsible for the monthly checks. The expired medication was found in the medication cart trash and was subsequently removed for proper disposal. Facility policy requires that medications be administered as prescribed, with doses checked against the Medication Administration Record and medication labels, and that physicians be notified when a dose is missed. In both cases, these procedures were not followed, resulting in a medication error rate of 7% during the observed period.