F0580

D

Failure to Notify Physician and Responsible Party After Repeated Medication Errors

Torrance, California Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a resident’s physician and responsible party after repeated medication administration errors and a significant deviation from ordered treatment parameters. The resident, who had type 2 DM, hemiplegia, hemiparesis, and severely impaired cognition, had a physician’s order for glipizide 2.5 mg once daily with instructions to hold the medication if the capillary blood glucose (CBG) was less than 120. Review of the Medication Administration Record showed that on multiple dates in March, the resident’s CBG levels were below 120, yet glipizide was administered at 9 a.m. on each of those days contrary to the physician’s order. The resident’s History and Physical and MDS documented that the resident lacked capacity to understand and make decisions and required extensive assistance with activities of daily living.

During interviews, the LVN who administered the glipizide acknowledged giving the medication when the CBG was less than 120 and stated he had not noticed the parameters on the order. He further stated he did not notify the physician of the medication administration errors. Review of the Order Summary Report, MAR, nursing progress notes, and change of condition reports confirmed there was no documentation of the errors, no change of condition report, and no notification to the physician or the resident’s family/responsible party. This failure occurred despite facility policies requiring immediate notification of the physician and resident representative for significant changes in condition or treatment, and immediate reporting and documentation of all medication errors, including notification of the attending physician, resident, and responsible party.