Failure to Notify POA After Significant Medication Error
Penalty
Summary
The facility failed to notify a resident's power-of-attorney (POA) in a timely manner following a significant medication error. A resident with multiple diagnoses, including dementia, diabetes, hypertension, and heart failure, was moderately cognitively impaired and dependent on staff for medication administration. On the morning of the incident, the resident was mistakenly given another resident's medications, which included several antihypertensive and antiplatelet drugs. Shortly after administration, the resident experienced symptoms of hypotension, including dizziness and persistently low blood pressure, requiring multiple interventions such as midodrine administration and attempted IV fluids. Documentation and interviews revealed that the medication error was discovered when the resident reported feeling dizzy, prompting staff to realize the mistake. The resident's blood pressure was monitored closely, and the nurse practitioner was contacted for further orders. Despite these clinical interventions and the resident's ongoing symptoms, there was no documented evidence that the resident's POA was notified of the medication error or the subsequent change in condition in a timely manner, as required by facility policy. The lack of timely notification was confirmed through interviews with nursing staff and review of the medical record. The resident ultimately contacted their POA directly, who then reached out to the facility to discuss the incident. Facility policy required prompt notification of a resident representative following a change in condition, but this was not followed in this case, resulting in a deficiency related to notification procedures.