Failure to Prevent Significant Medication Errors for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors for three of six residents reviewed. One resident, who had diagnoses including Parkinson's disease and localized edema, was not administered any of their prescribed medications or treatments for several consecutive days after returning from a hospital visit. The resident's medications, including carbidopa-levodopa for Parkinson's and hydrochlorothiazide for edema, as well as compression stockings, were placed on hold without documented discontinuation by a provider or clarification from the primary care provider, despite hospital discharge instructions to follow up regarding continuation of medications. Another resident with diabetes, dementia, and hypertension received insulin outside of the administration parameters specified in the medical order. This included instances where insulin was administered despite blood glucose levels being below the ordered threshold, and occasions where there was no documented evidence that a blood glucose measurement was obtained prior to insulin administration. Facility staff interviews confirmed that insulin should not be given without a recent blood glucose check, and that the timing of blood glucose monitoring in relation to insulin administration was not consistent with facility policy or physician orders. A third resident, also with diabetes, received insulin when their blood glucose was below the ordered hold parameter. The insulin was administered despite the order to hold if blood glucose was less than 100 mg/dL and/or if the patient was not eating. Staff interviews confirmed that the insulin should have been held and the provider notified, but this did not occur. These findings demonstrate that the facility did not consistently follow physician orders and facility policy regarding medication administration and documentation.