Failure to Prevent Significant Medication Errors and Wrong-Resident Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, including a double insulin dose and administration of another resident’s medications. Record review showed that the resident had diagnoses including type II diabetes, heart failure, kidney failure, anxiety, and depression, and was receiving insulin, antidepressant, diuretic, anticoagulant, hypoglycemic, and anticonvulsant medications. Nursing progress notes documented that on one occasion the resident was given Novolog 10 units twice by two different nurses because the first administration was not documented as given on the MAR, leading the second nurse to be unaware that the insulin had already been administered. On another occasion, an event report documented that the resident received a full set of medications intended for the roommate, including Xanax 0.5 mg, atorvastatin 40 mg, Aricept 10 mg, metoprolol 25 mg, Remeron 7.5 mg, Singulair 10 mg, ranolazine 500 mg, and ropinirole 1 mg. The error was described as involving the wrong resident and wrong medications, with the reason identified as wrong resident. During interview, an LPN stated she mistakenly administered the roommate’s medications to the resident. Another staff member (a QMA) indicated that nursing staff are expected to use the five rights of medication administration, and the facility’s policy required resident identification before medication administration by checking a photograph, calling the resident by name, having the resident verify their last name, or verifying identification with other personnel.
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