Failure to Prevent Significant Medication Errors and Adhere to Medication Administration Times
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of medications not in accordance with physician orders and prescribed timing requirements. Specifically, a resident with multiple complex diagnoses, including acute and subacute infective endocarditis, pneumonitis, a tibia fracture, cognitive communication deficit, and fibromyalgia, had physician orders for Oxycodone and Suboxone that required specific intervals between doses. The staff did not consistently separate Oxycodone doses by the required four hours or separate Oxycodone and Suboxone doses by the required two hours, resulting in at least 12 documented instances where these instructions were not followed. Additionally, the facility did not ensure that medications were administered within the required window of one hour before or after the scheduled administration time. Over the course of a month, there were 360 documented instances where medications were given outside of this window. These included a wide range of medications such as antibiotics, pain medications, and other routine prescriptions, with administration times often delayed by more than an hour from the scheduled time. The resident's care plan included directives for staff to administer medications as ordered and to promptly address pain management needs, including evaluating the effectiveness of interventions and compliance with dosing schedules. Despite these care plan interventions, the facility's staff failed to adhere to the prescribed medication administration protocols, leading to multiple medication errors and deviations from physician orders.