Failure to Administer Medications as Ordered Resulting in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that medications were administered as ordered, resulting in significant medication errors affecting three of six residents reviewed. For one resident with a diagnosis of allergic rhinitis and severely impaired vision, a physician's order for prednisolone acetate eye drops was changed to be administered only in the right eye each morning following an optometrist visit. However, the medication administration records showed that staff continued to administer the drops in both eyes, and the new order was not transcribed or updated in the records. Interviews with nursing staff and the Director of Nursing confirmed that the order change was missed and not implemented as required. Another resident with chronic viral hepatitis C, opioid dependence, and HIV had a physician's order for quetiapine 50 mg to be administered nightly. Upon admission, the medication was incorrectly entered into the medication administration record to be given in the morning instead of at night. This error persisted for several days until the order was corrected. Staff interviews revealed that the error occurred due to oversight during the transcription of hospital orders, and there was no documentation of adverse effects during the period the medication was administered at the wrong time. A third resident with acute respiratory failure, ventricular tachycardia, and atherosclerotic heart disease had a physician's order for clopidogrel bisulfate (Plavix) 75 mg daily. The medication administration records indicated that the medication was not administered on several specified dates, with no documentation or physician notification regarding the missed doses. Staff interviews confirmed that the medication should not have been held without appropriate clinical justification or documentation. Facility policy required medications to be administered as prescribed and within the specified time frame, which was not followed in these cases.