Medication Reconciliation and Administration Errors Result in Missed Antibiotic Therapy and Duplicate Antihypertensive Dosing
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors by not accurately reconciling hospital discharge medications and not ensuring timely and accurate medication administration. For one resident with a principal diagnosis of surgical aftercare following digestive system surgery, the facility did not properly transcribe a hospital discharge order for doxycycline, an antibiotic prescribed for a surgical wound infection. Instead, the order was incorrectly entered as pyridoxine (Vitamin B6), resulting in the resident missing six doses of the prescribed antibiotic. This error was identified after the resident was rehospitalized for wound dehiscence and infection, with documentation confirming the medication error and the delay in appropriate treatment. Another resident with a diagnosis of hypertension experienced a medication error when two different LPNs administered the same morning dose of antihypertensive medications, Lisinopril and Metoprolol, resulting in the resident receiving double the prescribed dosage. The error occurred because the first nurse failed to document the administration in the electronic medication administration record (EMAR) after being called away for an emergency, and the second nurse, seeing no documentation, administered the medications again. The incident was discovered later that morning, and the resident required close monitoring and intravenous fluids as a result of the double dosing. Both incidents were attributed to failures in following facility policy regarding medication reconciliation and administration, including accurate transcription of orders, timely documentation in the EMAR, and ensuring the five rights of medication administration. The deficiencies directly affected two of four sampled residents, resulting in missed antibiotic therapy and duplicate antihypertensive dosing, with one resident requiring rehospitalization for wound complications.