Significant Medication Errors Due to Admission Process Failures
Penalty
Summary
A facility failed to ensure residents were free from significant medication errors, resulting in a resident receiving multiple medications that were not prescribed to him. Upon admission, the admitting nurse entered medications into the resident's medical record without verifying them against an accurate and current medication list. The facility's physician subsequently signed off on these orders without reviewing or verifying the resident's diagnoses with the nurse. The records provided by the transferring facility included another resident's medication administration record (MAR) mixed in with the correct resident's records, leading to the erroneous transcription and administration of medications. The resident, who had a history of Parkinson's disease, vascular dementia, hypothyroidism, bradycardia, hyperlipidemia, anemia, and a cardiac pacemaker, was administered medications including Metformin, Insulin Glargine, Farxiga, Lasix, and Insulin Lispro, none of which were prescribed for him. The MAR and care plan did not accurately reflect the resident's diagnoses or medication needs. The error was discovered after the resident was found unresponsive, with abnormal vital signs and a sudden change in neurological status. The family was notified, and upon review, it was found that the resident had been given medications intended for another patient due to the mixed records. The resident was transferred to the hospital, where he was diagnosed with acute renal failure, aspiration pneumonia, and sepsis. The facility's internal investigation confirmed that the error stemmed from the admission process, where medication reconciliation was not properly performed, and the physician relied on nursing staff for accurate order entry. The incident was determined to be an Immediate Jeopardy situation due to the failure to provide necessary goods and services to avoid physical harm.
Removal Plan
- The resident was transferred to the hospital and no longer resides in the facility.
- The Director of Nursing (DON) or designee conducted a facility-wide review of all residents admitted or readmitted to ensure medication orders were accurately reconciled with hospital discharge instructions and physician orders, including any transfers from other facilities.
- Nursing supervisors verified MAR accuracy, medication availability, and physician clarification as needed. Any discrepancies identified were corrected.
- The Administrator reviewed the audit findings and confirmed that no additional residents were at risk.
- The staff member who input the orders was terminated by the DON.
- All staff will be in-serviced by the DON/designee on abuse, neglect, and misappropriation. Staff members who are not present will be in-serviced prior to working their next shift and before providing resident care. Completion will be verified and documented.
- Revised the admission and readmission medication reconciliation process to require dual verification confirming that admit orders/discharge summary matches the orders entered in the EMR by the admitting nurse and another licensed nurse.
- The DON/designee established a requirement for immediate physician notification, clarification, and documentation when discrepancies are identified.
- Updated the admission checklist to include MD verification, dual nurse verification, and DON/designee verification to be completed for every admission and readmission.
- The DON/Designee will verify that the admission checklist is completed for all admissions.
- Required DON or designee review of all new admissions and readmissions by next business day.
- The Director of Nursing (DON) or designee will provide re-education to all licensed nursing staff on proper medication reconciliation, verification of physician orders prior to medication administration, escalation procedures, and documentation requirements. Education will be provided by the DON/designee through in-service training, with staff competency validated through verbal review. Staff members who are not present will be in-serviced prior to working their next shift and before providing resident care. Completion will be verified and documented.
- Nursing management will notify the Regional Nurse of any significant medication error requiring physician intervention or hospitalization.
- The Regional nurse notified the administrator to in-service nurse management regarding notification of the regional nurse of any significant medication error requiring physician intervention or hospitalization.
- The Director of Nursing (DON) or designee will conduct weekly audits of all new admissions and readmissions to ensure continued compliance with medication reconciliation requirements.
- Audit results will be reviewed by the Administrator and incorporated into the facility's QAPI program.
- Any identified noncompliance will result in immediate corrective action and re-education.