Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first incident, a resident with diabetes mellitus type two was observed receiving insulin via a pen injector by an LPN who did not prime the pen prior to administration. The manufacturer's instructions for the insulin pen required priming before each use, and the facility's policy stated that nursing staff should have access to and follow manufacturer instructions for all insulin delivery systems. The LPN confirmed during interview that she did not prime the pen, directly contradicting both manufacturer guidance and facility policy. In the second incident, a resident with multiple complex medical conditions, including chronic respiratory failure, severe cognitive impairment, and a documented wound infection, experienced a significant delay in receiving a physician-ordered antibiotic. The wound culture results indicating infection were reported to the facility, but the responsible RN did not notify the physician until the following day, citing the end of her shift as the reason for the delay. After obtaining a verbal order for antibiotics, the RN entered the order to begin more than a day later, without checking the facility's medication supply or informing the physician of the delayed start. The antibiotic was available in the facility's automated medication machine at the time the order was given, but was not administered until 52 hours after the culture results were reported. Both incidents demonstrate failures to follow established protocols for timely and correct medication administration. The facility's policies required medications to be administered safely, timely, and as prescribed, and for staff to follow manufacturer instructions. In both cases, staff actions did not align with these requirements, resulting in significant medication errors affecting two residents.