Multiple Significant Medication Errors and Transcription Failures
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, despite a policy requiring accurate, safe, and timely medication administration. The policy directs staff to verify medication labels against the medication sheet for accuracy of drug, frequency, duration, strength, and route, and to check physician orders if there is any discrepancy. In multiple instances, staff did not follow these procedures, resulting in residents receiving wrong medications, wrong doses, wrong dosage forms, and discontinued medications that had not been removed from circulation. One cognitively intact resident with orthostatic hypotension and neurocognitive disorder with Lewy bodies was given another resident’s medications after an RN left a medication cart unattended between two rooms and then returned and handed the wrong medications to the resident. The medications included Oxycontin ER 20 mg and Amlodipine 5 mg, and the resident subsequently required Narcan and hospitalization, with hospital records later documenting marked orthostatic blood pressure changes requiring IV electrolytes and hydration. Another resident admitted with multiple rib fractures had an order for Oxycodone 5 mg every 6 hours for pain that was discontinued and changed to Hydrocodone 5-325 mg; however, the discontinued Oxycodone was not removed from circulation, and the resident received the wrong opioid medication on a later date. A resident on hospice care with chronic obstructive pulmonary disease, chronic pancreatitis, and generalized anxiety disorder was prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, but the medication was dispensed and administered in pill form instead of liquid on multiple dates. The Lorazepam was later discontinued but not removed from circulation, resulting in an additional dose being administered after discontinuation. Pharmacy review identified that another resident’s Tacrolimus dose was incorrectly transcribed in the medical record as 5 mg, two tablets twice daily instead of the ordered 0.5 mg, two tablets twice daily, and the resident received the wrong dose at morning administration. In separate incidents, one resident received another resident’s 40 mg Atorvastatin tablet, and another resident took another resident’s medications (gabapentin, clonidine, and Vitamin D) after medication cups were set at the bedside for two residents with the same initials, and one resident ingested the medications without checking the cup.
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