Based upon clinical record review and review of documentation provided to the State Agency by the facility, it was determined that the facility failed to ensure residents were free from medication errors for one of four residents reviewed (Resident R1).
Review of Resident R1's diagnosis list revealed diagnoses including diabetes mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), hypertension (high blood pressure), chronic kidney disease (progressive loss of kidney function), and coronary artery disease (CAD - narrowing of the blood vessels which supply the heart with blood and oxygen).
Review of Resident R1's progress notes dated November 19, 2019 revealed "Resident was given wrong med at 0530 [5:30 a.m.], RP [responsible person] and MD [medical doctor] aware, VS 129/64, 74, 95%, 97.9, 18, no pain or discomfort, no SOB, no chest pain, no H/A [headache] or dizziness, resident was given Gabapentin 600 mg [milligrams] [nerve pain medication and anti-convulsant medication] and Lisinopril-Hydrochlorothiazide [high blood pressure medicine and diuretic combination] 10 mg - 12.5 mg, neuro checks WNL [within normal limits], will continue to monitor."
Review of employee statement dated November 19, 2019 revealed "I gave resident the wrong medication. I gave [resident] Gabapentin 600 mg and Lisinopril-Hydrochlorothiazide tab. I had [resident's] med to give to [resident's] roommate and he noticed it was not his and I noticed that I gave [resident] the wrong med. VS [vital signs] were obtained 129/64, 74, 95% on oxygen, 97.9, 18, neuro checks WNL, no pain or discomfort, no dizziness, H/A or chest pain. MD called, RP called, will continue to monitor."
Interview with the Nursing Home Administrator and Director of Nursing on November 26, 2019 at approximately 2:45 p.m. confirmed that a medication error occurred with Resident R1.
| ||Plan of Correction - To be completed: 01/15/2020|
1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice?
Resident R1 experienced no ill effects from the medication error.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
New admissions and current residents who receive medication have the potential to be affected by the deficient practice. A comprehensive review of the last 30 days of incident reports using the medication error QAPI tool will be completed to ensure no other patients have been affected.
3. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
Licensed Nursing Staff will be educated on the facility procedure, Medication Administration: Oral.
4. How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?
The Director of Nursing/Designee will audit medication passes for 5 weeks (minimum of 3 per week). The results of the audits will be reviewed in QAPI to determine the need for continued audits.
5. Dates of when the corrective action will be completed.
January 15, 2020