A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
Medication Given Without Physician Order: An RN attempted to administer furosemide to a resident who had an order for torsemide 40 mg daily for edema. The RN stated she thought the two meds were the same and did not have a physician order to substitute them; another nurse retrieved the furosemide from the pyxis, and the surveyor stopped the administration before the incorrect med was given.
A resident with bacteremia did not receive an ordered daily IV daptomycin dose when the medication was unavailable, and nursing documentation was inconsistent between the EHR MAR and paper infusion records. Interviews showed one nurse expected another nurse to administer the dose when it arrived, while another nurse could not confirm giving it and later said she did not administer it. The physician stated the antibiotic was important to receive daily and should have been given once available.
Medication Administered Outside BP Parameters: A resident with A-fib, HTN, and a hx of sudden cardiac arrest had orders for Amlodipine and Enalapril to be held if SBP was less than 110 mmHg. Review of the MAR showed both meds were given multiple times when SBP was below the ordered threshold, and the UM and DON confirmed the meds should have been held per the physician orders.
A resident with latent TB and prior hepatotoxicity from Rifampin was admitted with hospital documentation indicating Rifampin was to be stopped indefinitely and not administered. Facility policy required use of the final hospital discharge summary and two‑nurse verification for medication reconciliation, but the Nursing Supervisor relied on a preliminary discharge summary, entered Rifampin as an active order after calling the on‑call provider, and the second nurse did not verify orders against the final discharge summary. No staff documented review of the finalized discharge instructions or clarification of the Rifampin order, and the resident received two doses of Rifampin before being transferred back to the hospital with recurrent liver injury symptoms.
A resident with autoimmune and connective tissue disorders was administered Methotrexate daily instead of weekly due to a transcription error during medication reconciliation. Multiple staff, including nursing and medical providers, failed to identify the incorrect dosing frequency, resulting in the resident receiving toxic levels of the medication and requiring hospital transfer for treatment of Methotrexate toxicity.
A nurse administered Epinephrine instead of Glucagon to a resident with diabetes who was experiencing hypoglycemia and unable to take oral glucose. The error occurred after the nurse was unable to access the medication room and obtained emergency medications from another unit, mistakenly selecting the EpiPen despite reviewing Glucagon instructions. The resident did not have an order for Epinephrine, and the error was discovered the following day.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition at the time.
A resident with a history of brain tumor, Parkinson's Disease, epilepsy, and Tardive Dyskinesia experienced significant medication errors when Ingrezza (Valbenazine Tosylate) was not administered as prescribed on ten occasions. The MAR showed missed or unrecorded doses, accidental discontinuation of the medication order, and lack of documentation or provider notification regarding the missed doses. Nursing staff and the provider were unclear about the medication's order status, and the DON confirmed the errors and gaps in administration.
A resident with epilepsy did not receive multiple doses of prescribed anti-convulsant medications due to unavailability, as confirmed by MAR review and staff interviews. Nursing staff reported contacting the pharmacy for delivery, but medications were not received in time, resulting in missed doses and non-compliance with physician orders.
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