Medication Error Due to Unordered Substitution of Probiotic for Prescribed Iron Supplement
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 33 opportunities, resulting in a 6.06% error rate during a medication pass for one resident. The resident involved had diagnoses including anemia, iron deficiency, and hyperlipidemia and a physician’s order for polysaccharide iron complex 150 mg by mouth once daily for deficiency. During a continuous observation of medication administration, the nurse assigned to the resident’s medication pass was unable to locate the ordered polysaccharide iron complex on her medication cart or in the medication storage room. Despite the absence of a corresponding physician order, the nurse poured an acidophilus 500 million tablet into the resident’s medication cup and stated that, since both medications were probiotics, one could be substituted for the other, then administered the acidophilus along with the resident’s other medications. Interviews with the nurse and multiple supervisory staff revealed differing descriptions of the process to follow when a medication is not available, including checking other carts, overstock, medication rooms, Pyxis, and contacting Central Supply, the provider, or family, depending on whether the medication was house stock, over-the-counter, or prescription. The DON later confirmed that polysaccharide iron complex and acidophilus are different medications and should not be substituted. The nurse practitioner stated that if a medication is not available, staff should notify him so he can place the medication on hold until it is received, and that acidophilus probiotic is not the same as polysaccharide iron complex and staff should not make such substitutions. He also stated that staff should have notified him of the administration of acidophilus in place of the ordered iron supplement, and that while no harm occurred, the resident did not receive the intended benefits of the prescribed polysaccharide iron complex.
Penalty
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Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain medication error rates below 5% when an LPN, during a medication pass for a resident receiving Metamucil for constipation and a cranberry supplement for UTI prevention, was unable to identify the correct dosages for these ordered medications. Despite a policy requiring adherence to the rights of medication administration, including the right dose, the LPN reported that the orders should have been clarified to specify the exact dose, indicating medications were being prepared and administered without clear dosage understanding and contributing to an overall medication error rate above the acceptable threshold.
Surveyors found that the facility did not maintain a medication error rate below 5%, identifying multiple late and improperly timed medication administrations and a missing medication. A medication aide gave a cholesterol medication and wound-healing supplements significantly later than their scheduled times, and another aide administered acetaminophen well outside the ordered time window and could not obtain a prescribed dose of Ingrezza because it had not arrived from the pharmacy. An LPN administered fast-acting Humalog insulin before a meal when no food was available and was unaware of the required timing of insulin in relation to meals, while the facility’s insulin policy lacked guidance on meal-related timing despite manufacturer instructions specifying administration within 15 minutes before or immediately after eating.
Surveyors identified a medication error rate of 7.41%, exceeding the 5% threshold, involving two residents and two LPNs. In one case, a resident with dementia and hypertension received 5 mg of donepezil instead of the 10 mg dose ordered. In another case, a resident with DM2 received insulin lispro via a KwikPen that was not primed, and the LPN held the dose knob for only about 2 seconds instead of the manufacturer-recommended 5 seconds. The DON reported that staff had not been educated on proper insulin pen priming, and facility policy requires verification of the correct medication and dose before administration.
Surveyors identified an 11.1% medication error rate when an LPN did not administer a resident’s ordered nifedipine ER dose because it was not available in the cart or pyxis, and proceeded with the rest of the medications. In a separate instance, an RN administered furosemide despite the order having been discontinued and gave magnesium oxide instead of the ordered SlowMag, explaining that he relied on scanning multi-drug packets rather than individually verifying each medication against the MAR, and knowingly substituted magnesium oxide when SlowMag was unavailable.
The facility failed to keep its medication error rate below 5% when a resident with dementia, COPD, diabetes, and depression did not receive ordered doses of Singulair and calcium/vitamin D3 because the medications were not available at the time of administration. An RN attempted to pass the morning medications but was unable to administer these two ordered drugs, and later confirmed their unavailability, resulting in two errors out of 33 medication opportunities and an overall error rate of 6.06%.
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Ensure Accurate Medication Dosage Identification During Medication Pass
Penalty
Summary
The facility failed to ensure medication error rates were kept below 5%, as evidenced by an LPN’s inability to identify correct dosages for ordered medications during a medication pass. The facility’s Medication Administration Policy, revised 4/15/26, required adherence to the rights of medication administration, including right drug, right dose, right time, right route, right patient/resident, and verification of accuracy if a resident questions a medication. During observation of a medication pass for Resident #3, who had physician orders for Metamucil 1 capsule by mouth daily for constipation and a cranberry supplement 2 capsules for cystitis (UTI) prevention, the LPN preparing and administering the medications was unable to identify the correct dosage for both the cranberry and Metamucil supplements. When questioned about the orders, the LPN stated that the orders should have been clarified to include the specific dose to administer, demonstrating that the medications were being prepared and administered without clear understanding of the correct dosage. This failure occurred despite the facility’s policy requiring verification of the right dose prior to administration and contributed to a medication error rate greater than 5%, with the potential to affect all residents receiving medications in the facility by increasing the risk of adverse health outcomes.
Failure to Maintain Acceptable Medication Error Rate and Proper Medication Timing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 39 opportunities, resulting in a 12.82% error rate. The facility’s policy allowed medications to be given within one hour before or after the scheduled time, but staff did not adhere to this window. One medication aide administered pravastatin 10 mg to a resident at 8:52 PM when it was scheduled for 7:00 PM, and confirmed it was given late. The same aide also administered LiquaCel 30 cc and Juven 1 packet to another resident at 9:20 PM, despite orders for these supplements to be given twice daily with morning and evening medications at 8:00 AM and 7:00 PM, and confirmed these were also late. Additional errors involved improper timing and availability of medications. An LPN administered 4 units of Humalog, a fast-acting mealtime insulin ordered to be given before meals, to a resident at 7:37 AM when the resident had no food present and did not receive a meal tray until 8:18 AM; the LPN stated they did not know how quickly food should be provided after fast-acting insulin. The facility’s insulin policy lacked guidance on timing relative to meals, while the manufacturer’s prescribing information specified administration within 15 minutes before or immediately after a meal. Another medication aide administered acetaminophen 500 mg (two tablets) at 7:30 AM instead of the scheduled 6:00 AM dose and was unable to locate the resident’s ordered Ingrezza 80 mg capsule, confirming the medication had not arrived from the pharmacy and required reordering. The DON confirmed that the acetaminophen should have been given at 6:00 AM.
Medication Error Rate Above 5% Due to Incorrect Dosing and Insulin Pen Technique
Penalty
Summary
The facility failed to ensure the medication error rate was below 5%, with surveyors identifying 2 errors out of 27 observed medication administration opportunities, resulting in a 7.41% error rate. In one instance, an LPN administered multiple oral medications to a resident with cerebral atherosclerosis, vascular dementia, dementia, and hypertension, including donepezil 5 mg. The resident’s active orders, however, specified donepezil HCl 10 mg by mouth once daily for dementia, meaning the resident received only half of the prescribed dose. The LPN confirmed the tablets prior to administration, but the dose given did not match the active physician order. In a second instance, another LPN administered insulin lispro (Humalog KwikPen) to a resident with type 2 diabetes mellitus after obtaining a blood glucose level of 234 and dialing the pen to 3 units per the sliding scale order. The LPN stated she does not prime the insulin pen prior to administration and proceeded to inject the dose into the resident’s left lower abdomen, holding the dose knob for approximately 2 seconds. Manufacturer instructions for the Humalog KwikPen require priming before each injection to remove air and ensure correct dosing, and instruct holding the dose knob in place while counting to 5 seconds. The Interim DON acknowledged she had not provided staff education on insulin pen priming, could not properly demonstrate priming, and confirmed that priming is necessary to provide the correct insulin dose. Facility policy on administering medications requires verification of the right medication and right dosage before administration.
Medication Administration Errors and Unavailable Ordered Medications
Penalty
Summary
The deficiency involves failure to ensure medications were administered in accordance with physician orders, resulting in three medication errors out of 26 opportunities and an 11.1% medication error rate. In one instance, an LPN preparing a resident’s morning medications found that nifedipine ER 60 mg, ordered once daily since 02/13/25, was not available in the medication cart or the pyxis machine. The LPN stated she would contact the pharmacy, documented that the nifedipine was unavailable for administration, and proceeded to offer the remainder of the resident’s medications without administering the ordered nifedipine dose. In another instance, an RN administering medications to a different resident gave one tablet of furosemide 40 mg and one tablet of magnesium oxide 400 mg. Review of the resident’s orders showed there was no current order for furosemide, as the most recent order had been discontinued on 12/19/24, and that the resident instead had an active order for two SlowMag Muscle/Heart delayed-release tablets (magnesium chloride–calcium carbonate) twice daily rather than magnesium oxide. The RN reported that he did not individually check each medication in the multi-drug packets, relying instead on scanning the barcodes on the packets and only looking for medications flagged as missing. He further stated he administered magnesium oxide because SlowMag was not available and confirmed he knew the two medications were not the same. The facility’s medication administration policy required medications to be given only as prescribed, adherence to the five rights of medication administration, and reading the medication label three times while comparing it to the MAR.
Medication Error Rate Exceeded Due to Unavailable Ordered Medications
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 6.06% (two errors out of 33 medication opportunities) during a complaint investigation. Resident #15, admitted on 01/01/21 with dementia, chronic obstructive pulmonary disease, diabetes mellitus, and depression, was cognitively impaired and dependent on staff for activities of daily living per the 03/10/26 MDS assessment. Physician orders dated 02/06/26 directed that the resident receive Singulair 10 mg daily and calcium/vitamin D3 500 mg/5 mcg every morning and at bedtime. On 04/28/26 at 8:24 A.M., observation of medication administration by RN #105 showed that neither Singulair nor calcium/vitamin D3 was given because the medications were not available for administration. In an interview at 8:34 A.M. the same day, RN #105 confirmed that these ordered medications were not available to be administered as prescribed, contributing to the identified medication error rate above 5%.
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