Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors. One resident with cellulitis, anemia, and depression, and with moderate cognitive impairment, had a physician’s order for IV meropenem every eight hours for cellulitis of both lower extremities. The care plan included administering medications as ordered. On one occasion, an LPN attempted to administer the ordered meropenem but instead hung and began infusing daptomycin, an IV antibiotic intended for another resident. The LPN did not double-check the medication before starting the infusion and only realized the error after the resident reported receiving the wrong medication approximately ten minutes after the infusion had started. Documentation showed the meropenem was recorded as administered, and both the resident and the LPN confirmed that the wrong antibiotic had been started. Another resident with chronic respiratory failure, diabetes mellitus, depression, and anxiety had a physician’s order for lorazepam 1 mg every eight hours for anxiety. Review of the MAR showed multiple missed doses over several days, with entries indicating the drug was not available and that pharmacy delivery was pending. Nursing progress notes documented that the medication was on order and unavailable, but there was no documentation explaining why lorazepam was not administered on subsequent days when doses were also missed. The resident reported not receiving medications as ordered and stated the facility had failed to order the medication. A psychotherapist reported the resident had high anxiety and was very upset about not receiving the ordered medication, and an LPN confirmed the lorazepam was not administered as ordered because it was unavailable, contrary to the facility’s policy that medications are to be administered in a safe and timely manner as prescribed.
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