WESTMINSTER, CO-LIFE CARE CENTER OF WESTMINSTER

Based on record review and interview, the facility failed to ensure two (#58 and #8) of three residents out of 32 sample residents did not experience a significant medication error.
Specifically, the facility failed to ensure
-For Resident #58, ensure the prescribed physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER]
-For Resident #58 recognize signs and symptoms of over sedation due to the medication transcription error
of [MEDICATION(S)]; and,
-For Resident #8 follow physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Resident #58, age 98, admitted on [DATE]. According to the May 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was receiving 1 mg (0.5ml) of [MEDICATION(S)] routinely, four times per day. 

Resident #58’s representative was interviewed on 5/9/22 at 3:11 p.m.She said the resident was very sleepy and hard to awaken today. She was unaware Resident #58 was prescribed routine [MEDICATION(S)] (antianxiety medication, see orders below), and was concerned this was causing her to be sleepy.

The DON was interviewed on 5/11/22 at 8:45 a.m. She said she did not know why the resident was on routine Lorzpam. She said there should have been a progress note or documentation in the behavior binder to support the use of the [MEDICATION(S)] routinely. The DON said hospice had provided the order for the [MEDICATION(S)] to be given routinely four times per day on 4/26/22. She said the resident was already on as needed [MEDICATION(S)]. The DON said Resident #58 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said it was possible the [MEDICATION(S)] was making the resident sleepy as a side effect.

The DON was interviewed again on 5/12/22 at 1:39 p.m. She provided a copy of the same original order from hospice for the [MEDICATION(S)] to be given as needed not every four hours routine. She said it was a medication error. The DON said the nurse interpreted the order wrong. She said she would be inservicing the licensed nurse on medication transcription and ensuring orders or correct. She said the licensed nurse who transcribed the order should have questioned why the resident was being prescribed [MEDICATION(S)] 1mg four times a day when she had no behavior changes or changes in restlessness or behaviors to support the use of the [MEDICATION(S)] four times per day routinely.

Resident #8, under the age of 78, admitted [DATE]. According to the May 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

The DON was interviewed on 5/10/22 at 11:27 a.m. The DON said the nurses should have been holding Resident #8’s [MEDICATION(S)] when the resident’s morning BG levels were below 100 and when the evening BG levels were under 150; and when this order was not followed, it was a medication error.

On 4/18/22 the resident’s morning BG level was 95; the [MEDICATION(S)] injection was not held.
On 4/18/22 the resident’s evening BG level was 117; the [MEDICATION(S)] injection was not held.
On 4/19/22 the resident’s morning BG level was 85; the [MEDICATION(S)] injection was not held.
On 4/20/22 the resident’s morning BG level was 95; the [MEDICATION(S)] injection was not held. On 5/2/22 the resident’s morning BG level was 86; the [MEDICATION(S)] injection was not held. On 5/6/22 the resident’s evening BG level was 134; the [MEDICATION(S)] injection was not held.
On 5/7/22 the resident’s evening BG level was 120; the [MEDICATION(S)] injection was not held.
On 5/8/22 the resident’s evening BG level was 120; the [MEDICATION(S)] injection was not held.
On 5/10/22 the resident’s morning BG level was 97; the [MEDICATION(S)] injection was not held

The DON said she would be notifying the resident physician to notify the physician of the error to see if the physician wanted to provide further direction or new orders based on resident results. The DON said she would speak to the nurses about expectations to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .