Medication Error and Failure to Follow Post-Error Vital Sign Orders
Penalty
Summary
The deficiency involves a medication error and failure to follow subsequent physician orders for monitoring. A resident admitted with small bowel obstruction and bladder cancer was ordered Lactulose 30 cc PO for constipation. On the evening in question, a nurse poured Keppra into a medication cup, then discarded the liquid but left a minimal amount in the cup and subsequently poured the ordered Lactulose into the same cup. As a result, the resident received 5 ml of Keppra PO instead of the ordered Lactulose dose. The error was identified later during a MAR review at 9:30 p.m. The DON confirmed that the resident’s medication order was not correctly followed and that the resident was accidentally administered Keppra. Following the medication error, the physician was notified and ordered vital signs to be monitored every shift for two days. Progress notes documented this order, but the clinical records showed that complete vital signs (BP, respirations, pulse, temperature) were only taken once, shortly after the error. Subsequent entries on the following days documented only blood pressure readings, with no complete set of vital signs recorded for multiple shifts and some shifts with no vital signs taken at all. The DON confirmed that the physician’s order for vital sign monitoring after the medication error was not followed and reported that the order was placed in the physician’s orders but was not properly transcribed into the EMR. The facility therefore failed to ensure that the physician’s order for post-error vital sign monitoring was implemented and documented as ordered.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.