Significant Medication Errors Due to Missed Insulin Doses and Failure to Discontinue Steroid
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by missed doses of scheduled rapid-acting insulin for two residents and a failure to discontinue a steroid medication as recommended for another resident. For two residents with diabetes, scheduled doses of insulin aspart were not administered in the morning due to a staffing issue. The Medication Administration Records (MAR) indicated that the morning doses were missed, and there was no documentation of blood sugar readings prior to the scheduled administration times. The nurse on duty reported that he was only notified of the need to pass medications after arriving late, and by that time, it was already time for the next scheduled insulin doses. The physician was informed and directed staff to hold the missed doses and proceed with the next scheduled administration. Both residents did not experience adverse events from the missed doses, but the medications were not given as ordered. Another resident with a diagnosis of pulmonary sarcoidosis continued to receive prednisone, a corticosteroid, despite a pulmonologist's consultation recommending discontinuation of the medication. The consultation report was signed by the unit manager, but the order to discontinue prednisone was not implemented until several months later. The MAR showed that the resident continued to receive prednisone every other day until the order was finally discontinued. Interviews with the previous DON and medical directors revealed that the consultation report was either not reviewed with the physician or the recommendation was not acted upon in a timely manner. The administrator was unaware that the consultation report had not been reviewed and that the medication had not been discontinued as recommended. These deficiencies were identified through record review, staff and resident interviews, and review of consultation reports. The facility's failure to administer medications as ordered and to follow up on consultation recommendations resulted in significant medication errors for three residents. The events were attributed to staffing issues, lack of communication, and failure to implement physician recommendations in a timely manner.