Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were protected from significant medication errors, as evidenced by two documented incidents involving medication administration. For one resident with multiple diagnoses, including aftercare for a right femur fracture and psychiatric conditions, the physician's order specified lurasidone 100 mg daily, to be given as 20 mg and 80 mg together. However, the Medication Administration Record (MAR) showed the doses were administered separately at different times over a ten-day period, contrary to the order. The Director of Nursing (DON) reviewed the records and could not explain why the doses were divided during that period. In another case, an LPN administered Lyrica 75 mg and auvelity 45-105 mg, both controlled and antipsychotic medications, to the wrong resident. The medication was intended for a different resident in another room. The error was documented in a medication error report, and both the affected resident and her husband were upset, though no physical harm was noted. The DON confirmed the LPN reported the error and accepted responsibility.