Failure to Assess and Monitor Resident After Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care, including assessment and monitoring, after a medication error involving Resident B. An LPN reported witnessing an RN administer one of Resident E’s morning medications to Resident B; this was later identified by the NP as rivastigmine 3 mg, a medication used to treat dementia. The NP stated that when the error was reported, she instructed the LPN to monitor Resident B’s vital signs and observe for anxiety and tremors every shift for 24 hours. The facility’s Medication Error policy required the nurse to assess and examine the resident’s condition, monitor and document the resident’s condition and response to interventions, and document actions taken in the medical record when a medication error occurs. Despite these requirements and the NP’s specific instructions, the Regional Nurse Consultant reported that there was no assessment, no progress note, and no vital signs documented in the EHR for Resident B following administration of Resident E’s medication. The floor nurse was identified as responsible for ensuring this was completed. Resident B’s clinical record indicated multiple diagnoses, including diabetes, chronic kidney disease, osteoporosis, hypertension, congestive heart failure, depression, anxiety disorder, intellectual disability, and a history of cerebral infarction, and an MDS assessment showed moderately impaired daily decision-making. The lack of documented assessment, monitoring, and vital signs after the medication error constituted the failure to provide care and services in accordance with physician orders, resident needs, and facility policy.
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