A resident with dementia and Alzheimer's disease ingested another resident's crushed medications after an RN prepared the medications in a glass, placed it in front of the intended resident, and walked away, leaving it unattended. The cognitively impaired resident took the glass, drank the contents, and became lethargic, with her pulse dropping from her usual rate to the 30s–40s bpm. She was sent to the ED, where it was determined she had ingested multiple medications, including metoprolol, and was diagnosed with a medication overdose and bradycardia requiring IV fluids and glucagon.
A resident with diabetes and multiple comorbidities experienced significant medication errors when rapid-acting insulin aspart, ordered as a sliding scale to be given with meals, was administered mid-afternoon without a meal and then inaccurately documented on the eMAR as noon and evening doses. Later that day, the resident was found incoherent, cold, and clammy with critically low blood glucose and required transfer to the hospital. Surveyors also observed that the same resident’s scheduled morning medications, including insulin glargine, cardiac, anticoagulant, pain, and respiratory drugs, were administered nearly three hours late, and the resident reported that medications were often more than an hour late, affecting pain control and breathing. The NP and pharmacist confirmed that rapid-acting insulin should not be given between meals and that key medications should be administered on a consistent schedule, while the DON and Administrator acknowledged these were medication errors.
A resident with hypomagnesemia and multiple serious diagnoses had an order for oral magnesium 250 mg daily that was not administered for five consecutive days, with MAR entries coded as unavailable and nursing notes stating the medication was on order or awaiting pharmacy delivery. Magnesium was an OTC item stocked in the facility, but the correct strength was not requested via house stock procedures, and the provider was not notified of the missed doses. During this time, labs showed persistently low magnesium, and documentation noted fatigue, lethargy, nausea, poor intake, and leg pain. An NP later documented that the resident’s magnesium supplement had not been started due to tablet strength issues, the pharmacy reported no request for the ordered dose, and the DON learned of the omissions only on later chart review. The Pharm-D characterized the five missed doses, in the context of the resident’s symptoms and lab values, as a significant medication error.
Surveyors identified significant medication errors involving two residents. One resident with cardiac and neurologic conditions received conflicting and duplicate metoprolol orders that were not clarified, resulting in administration of both metoprolol succinate and metoprolol tartrate at overlapping doses and frequencies. Facility staff failed to reconcile discrepancies between hospital, cardiology, and pharmacy orders, did not complete required verification checks for telephone orders, and documented ongoing administration of incorrect dosing on the MAR while the resident reported dizziness and feeling worse. A second post-surgical resident with cervical spine fusion did not receive ordered PRN oxycodone and acetaminophen in a timely manner; pain medications were not available on admission, the resident experienced severe pain before receiving relief, and documentation showed both a delay in initial dosing and administration of oxycodone at intervals shorter than the every-4-hours PRN order. Interviews confirmed breakdowns in following established processes for obtaining and administering medications from the pharmacy and the facility’s medication bank.
A resident with complex cardiac and renal conditions was given another resident’s full set of morning medications when an agency TMA entered the wrong room and failed to verify identity or follow the rights of medication administration, leading to unresponsiveness, hypotension, and acute kidney injury requiring hospitalization. During observation of other medication passes, an RN misread an order for an oral antifungal as “swish and spit” instead of the ordered “swish and swallow,” and another resident with heart failure, Parkinson’s disease, dementia, and hospice services received an extra scheduled dose of lorazepam when a TMA assumed there was a PRN order and did not verify the MAR. Multiple TMAs and an RN demonstrated incomplete understanding of the rights of medication administration, and medication pass audits and competencies had been performed by an unlicensed administrator without formal medication training and by LPNs, despite facility policy requiring verification of resident identity and triple-checking the right resident, medication, dose, time, and route.
A resident with recent CVA, hypokalemia, and multiple comorbidities was discharged from the hospital with an e-prescribed order for potassium chloride 10 mEq BID, which the pharmacy confirmed and delivered to the facility. The potassium order was not included on the paper transfer orders and was not entered into the EMAR on admission. A TMA received the potassium, noted it was not on the EMAR, did not administer it, and left the medication on the medication room counter with a note, without documented communication to nursing leadership. The potassium remained unused through multiple shifts until a night-shift RN later discovered the untouched card, located the hospital order, and entered it into the resident’s record, at which point administration began. Facility documentation identified that at least six doses of potassium were missed during this period and classified this as a medication error, reflecting a failure to ensure the resident was free from significant medication errors.
A resident with CHF and chronic respiratory failure was discharged from the hospital with an order for Furosemide 40 mg daily, but facility staff failed to transcribe this order into the EHR and did not initiate the CHF order set, including daily weights and respiratory monitoring. The resident was not placed on daily weights at admission, later showed significant, documented weight gain over multiple days, and received no Furosemide doses for 13 consecutive days, as confirmed by the MAR. The medication error was discovered only after an outside vascular clinic requested medication and weight information, prompting staff to review the hospital discharge summary and recognize that the Furosemide order and CHF order set had been omitted. Interviews with an LPN and an RN revealed distractions during admission order transcription and failure to identify the CHF diagnosis, and subsequent documentation showed the resident experienced rapid weight gain, worsening respiratory status, hypoxia, and hospitalization for acute on chronic CHF and hypoxic respiratory failure.
A resident with a seizure disorder and encephalopathy, prescribed Lacosamide 200 mg BID, missed multiple consecutive doses when nurses documented the drug as "not available" and failed to notify the provider, pharmacy, or nurse management as required. Over several days, three different LPNs did not administer scheduled doses, did not consistently reorder the medication, and did not hand off the issue in report, even though seizure monitoring was checked off on the TAR without documented results. An RN later found the resident very difficult to arouse and withheld medications, including the anti-seizure drug, and the resident was subsequently found actively seizing and transferred to the ICU, where records noted the resident had been without Lacosamide for several days.
A resident was given a 16-fold overdose of methadone after a handwritten order was incorrectly transcribed into the electronic health record and not properly double-checked. The nurse administered the dose listed in the MAR despite noticing a discrepancy with the medication bottle, resulting in the resident requiring Narcan and ICU admission for opioid overdose.
A resident receiving hospice care was administered ten times the prescribed dose of liquid morphine after a hospice nurse incorrectly transcribed the order, and a facility nurse failed to question or verify the unusually large dose before administration. The error was discovered when a new medication bottle arrived with the correct dosage, and the resident required multiple doses of Narcan to reverse the effects. Staff interviews revealed a lack of double-checking for hospice orders and inconsistencies in documentation of the incident.
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