A resident with type 1 DM, who was cognitively intact and ordered insulin lispro 20 units SQ before meals with pre-administration blood glucose checks, did not receive the ordered morning insulin dose. After the resident reported having eaten breakfast, an LPN obtained a blood glucose of 205 mg/dl, discovered the insulin vial was empty, and then administered the resident’s other medications but did not obtain insulin from other facility sources, notify a supervisor, or call the pharmacy at that time. The LPN later documented on the MAR that the blood sugar was 125 mg/dl and that the insulin was given, despite it not being administered. A subsequent lunchtime blood glucose by an RN was 191 mg/dl, and documentation that the morning insulin dose was missed was entered only after the issue was raised to facility leadership.
An LPN prepared propranolol 20 mg instead of the ordered Seroquel for a resident with dementia and severe cognitive impairment, then documented Seroquel as given on the MAR. The error was identified before the medication was administered, and the DON stated the resident could have had an adverse reaction if propranolol had been given instead of the prescribed medication.
A resident with CHF and multiple comorbidities was readmitted from the hospital with an order for metolazone 2.5 mg PRN, to be given only when weight increased by 5 lbs over baseline and 30 minutes before Lasix. Due to incorrect transcription of the hospital discharge orders into the EMR by the ADON, and the absence of a required second-nurse verification, metolazone was entered and administered as a scheduled daily medication instead of PRN. Nursing staff gave the drug daily for eight days without confirming the weight-based parameter, including on days when no weight was obtained and when the resident’s weight was stable or decreasing. During this period, the resident experienced a 12–14 lb weight loss, marked weakness, fatigue, excessive somnolence, and was later found to have hypokalemia, while continuing on other diuretics (Lasix and spironolactone). Interviews with the resident, her representative, nursing staff, the DON, PCP, and pharmacist linked these changes to the medication error, which did not follow the prescriber’s PRN order or the facility’s medication error policy.
A resident with epilepsy and renal failure on hemodialysis had a complex antiepileptic regimen including phenobarbital, lacosamide, clobazam, Depakote, later Tegretol, and PRN post-dialysis seizure medications. The facility repeatedly failed to administer multiple scheduled doses of these medications, including entire mornings when all seizure meds were omitted, and never gave the ordered PRN post-dialysis doses despite ongoing seizures. Staff followed an informal practice of holding medications when the resident was at dialysis without clarifying orders with the PCP or neurologist, and nurses missed additional Tegretol doses because they were unaware the drug was available in a separate storage area. The EMR lacked documentation that the neurologist or PCP were notified of these missed doses, while hospital records documented breakthrough seizures and subtherapeutic antiepileptic levels. An additional observation showed a nurse unable to locate an ordered inhaler for another resident and not notifying the physician or documenting the omission, illustrating broader medication administration failures.
Surveyors found that the facility failed to prevent significant medication errors for two residents. One resident with complex medical and SUD history had an external addiction provider order increasing Methadone from 40 mg to 50 mg for relapse prevention, but facility orders and MARs were not updated for over a month, doses were documented and administered as 40 mg against the external order, narcotic count sheets lacked required strength documentation, and care plans did not address Methadone use or SUD triggers. The same resident became unresponsive and was given Narcan without a prior standing order or documented physician order, and the Narcan administration was not recorded on the MAR. Another resident ordered Doxycycline 100 mg BID for infection missed multiple doses, with blank MAR entries and no corresponding explanatory progress note, and documentation inconsistencies showed the antibiotic recorded as given before it had arrived from the pharmacy.
A resident with type 1 DM and a history of low BG had orders for Lantus 29 units HS and Humalog per sliding scale before meals. An RN mistakenly administered 29 units of Humalog instead of the ordered Lantus at bedtime, then administered the Lantus as well without first consulting a provider. The RN instructed the resident to self-monitor BG every 20–30 minutes and encouraged intake of sugary foods, but did not perform or document serial BG checks, vital signs, or a full assessment. Despite notifying the DON and the on-call service, the RN did not immediately send the resident to the ED as directed, instead delaying EMS transport for several hours while the resident’s BG dropped to severely hypoglycemic levels, ultimately requiring EMS-administered oral glucose and hospital monitoring for recurrent hypoglycemia.
A resident with orthostatic hypotension, dementia, chronic kidney disease, and other comorbidities had a physician order for midodrine with a hold parameter to stop the dose when systolic BP exceeded 100 mmHg. Review of the MAR showed that nursing staff administered midodrine 49 times despite documented systolic BP readings above the ordered threshold. Facility policy required medications to be given exactly as prescribed and vital signs to be obtained and reviewed before administration, but interviews with the regional nurse, medical director, NHA, and nursing staff confirmed a systemic pattern of not following BP parameters for this medication, resulting in a significant medication error.
A resident with multiple chronic conditions was given warfarin twice daily instead of the prescribed once daily due to a failure to discontinue a previous order and inaccurate documentation of INR results. This led to the resident receiving excessive doses of the anticoagulant over several days, with staff not updating the MAR with current INR values or completing scheduled INR testing.
A resident with HIV did not receive the prescribed antiretroviral medication, Biktarvy, due to a transcription error by an LPN, resulting in the administration of only one component of the therapy. The error went uncorrected by nursing staff, the pharmacist, and the medical director, and was only discovered after the resident was hospitalized for routine viral load testing, which revealed a high viral load and absence of the correct medication on the facility's records.
Two residents were administered other residents' medications due to failures in verifying patient identity and following medication administration protocols. One resident was hospitalized after receiving antihypertensives and an opioid not prescribed to her, while another became lethargic after receiving his roommate's medications following a room switch that was not updated in the EMR. Both incidents were linked to staff not properly confirming resident identity and not adhering to established procedures.
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