A resident with a history of stroke and seizure disorder was ordered Vimpat 50 mg PO BID, but an incorrect 200 mg BID dose was entered into a separate e-script system and filled by the pharmacy. The eMAR continued to show a 50 mg dose, yet four LPNs administered 200 mg tablets for four doses, as evidenced by missing tablets and narcotic count signatures, while documenting 50 mg on the MAR. The DON later explained that the EMR used for orders was not linked to the narcotic e-script system and there was no reconciliation process between the e-scripted narcotic order and the physician order in the chart, leading to the resident receiving a higher-than-ordered dose.
The facility failed to ensure methadone was administered according to physician orders, resulting in significant medication errors for multiple residents on methadone maintenance therapy. Policy required nurses to use the eMAR as the source for medication administration and to verify the five rights, but methadone bottles for several residents carried doses that did not match the physician orders entered in the electronic record, despite daily administration being documented. Nursing staff reported either not cross-checking bottle dosages against orders or relying solely on the bottle label or resident familiarity, and they often did not notice discrepancies. The attending physician, DON, and medical director described a process in which the methadone clinic determined doses, nurses transcribed bottle labels or clinic information into the electronic record, and physicians signed orders without independent verification or direct clinic documentation, contributing to inconsistent and inaccurate methadone dosing information.
A resident with Parkinson’s disease, dementia, and anxiety received another resident’s potent medications, including opioids and other CNS-acting drugs, after an LPN pre-poured medications for about 20 residents and misidentified a pill, administering the wrong medication cup. Facility policy required correct resident identification and adherence to the six rights of medication administration, but the LPN’s pre-pouring and misadministration led to the resident receiving an incorrect regimen. Subsequent documentation showed hypotension, bradycardia, lethargy, and decreased respirations, with limited and delayed physician notification and incomplete nursing documentation of the resident’s changing condition, culminating in the need for Narcan as ordered by the physician.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
A resident with neurocognitive disorder, Parkinson’s disease, and epilepsy, who was otherwise cognitively intact and largely independent, was found with a medication cup at the bedside containing one whole and one half white pill. Facility policy required nurses to remain with residents until medications were swallowed and prohibited leaving medications at the bedside without a physician’s order, and a separate self-administration policy required an IDT evaluation and care plan documentation before self-medication. An LPN reported the pills were levodopa, had already signed the dose as given before the resident took it, and admitted leaving the room while the medication remained in the cup, even though the resident had no order to self-administer. The RN unit manager confirmed that no residents on the unit had self-medication orders and that medications should not be left at the bedside.
A resident with COPD, diabetes, heart failure, and depression had multiple scheduled medications and continuous O2 at 3 L/min ordered for the evening shift, but an RN did not administer the 4 PM, 8 PM, or 9 PM doses and did not ensure the resident received ordered oxygen, nor did the RN notify a supervisor or MD of the missed doses. The RN assumed the resident was with a visitor, did not verify the resident’s return, and only began looking for the resident later in the shift. The resident was ultimately found on the floor unresponsive without O2 in place, CPR was initiated, EMS assumed care, and the resident was pronounced deceased. Supervisory staff and the MD reported they were not informed during the shift that the resident was missing or that medications and oxygen had not been provided, and records showed no hourly safety checks or medication administration during the relevant period.
Surveyors found that the facility failed to administer medications according to provider orders and required timeframes, and failed to document or notify providers when medications were omitted or given late. Multiple cognitively intact and cognitively impaired residents with conditions such as DM, CHF, respiratory failure, seizure disorder, CVA history, osteomyelitis, and HTN had numerous blank MAR entries indicating missed doses of high‑risk medications, including insulin, anticoagulants, anti‑seizure drugs, cardiac medications, antibiotics, and controlled pain medications. One resident received duplicate and excess dosing of oxycodone due to overlapping active orders, along with frequent missed and late insulin and other scheduled medications. EHR audits showed hundreds of instances of medications administered more than one hour late for several residents, and narcotic count sheets contained missing entries. Residents reported frequent delays and missed medications, and clinical leaders acknowledged that medications were not consistently administered as ordered and that providers were not reliably notified of omissions or late administrations.
A resident with dementia, depression, and psychosis was re-admitted with an order for Clozapine 100 mg, 1.75 tablets at bedtime. The pharmacy notified the facility that the tablets could not be cut as ordered and requested a revised order using 100 mg and 25 mg tablets together, but staff did not obtain physician clarification at that time. An LPN continued to administer Clozapine over several days, including using 25 mg tablets intended for a different order without physician authorization, and the medication was not available at the scheduled administration time due to late pharmacy delivery. The original Clozapine order remained active until it was discontinued and rewritten days later, contrary to facility policy requiring prompt review and clarification of unclear or potentially inappropriate orders.
A resident with multiple chronic conditions and a documented allergy to Vancomycin received IV Vancomycin after a new order was written and processed. The allergy had been added to the care plan and physician orders, and the pharmacy profile reflected the allergy, but the pharmacy’s dispensing system was not updated to flag it, and the RN who administered the dose failed to check the allergy information. The resident subsequently developed increased work of breathing and facial and lip swelling while receiving the infusion, and a medication error report cited failure to check allergies as the cause.
A resident with anxiety, major depression, schizophrenia, anticoagulant therapy, tardive dyskinesia, and fibromyalgia did not receive all ordered bedtime medications when an LPN found that some medications were not in the med cart and did not use available pill packs in the med room. The LPN administered only narcotics and stock medications, failed to notify the nursing supervisor, pharmacy, or physician that medications were unavailable, and documented in the eMAR that all bedtime medications were given. There was no progress note indicating omitted doses or provider notification, and the resident later reported not receiving their medications and complained of worsened tardive dyskinesia symptoms, while the physician and nursing staff reported they had not been informed of the omissions.
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