Failure to Administer Medications as Ordered and to Report Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered and to properly recognize and manage a medication error for one cognitively intact resident. The resident was admitted with multiple diagnoses including a left pubis fracture, UTI, heart failure, atrial fibrillation, hypertension, chronic kidney disease, and hyperkalemia, and had a BIMS score of 15. Progress notes show that on one shift the resident was given Keppra 750 mg and Metoprolol 100 mg in error, despite having no physician orders for either medication in the order history covering the relevant period. Nursing documentation states that the error was recognized, the on‑call nurse practitioner was notified, vital signs were monitored, and no adverse reactions were noted, with a subsequent note indicating no adverse side effects from the medication error on the following shift. However, the facility’s leadership and systems did not identify or track this medication error as required. The DON initially stated there had been no medication errors and that the facility had no medication error reports. One LPN reported that a night‑shift nurse had given the wrong medications to the wrong resident and that this had been reported to the DON, but the DON and the ADON both stated they were not aware of any medication errors. The LPN who made the error later described helping another nurse with a med pass, pulling medications from the med cart for a resident in one room but administering them to a different resident in another room, and stated she reported the incident and documented it. The DON subsequently acknowledged only learning of the event days later during surveyor questioning and had to review charts to determine which resident was involved. The administrator also stated he was not made aware of the medication error until the survey, despite facility policy requiring documentation of the error and forwarding incident reports to nursing administration and the consultant pharmacist.
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