A resident with peripheral vascular disease and a left above-knee amputation, who was moderately cognitively impaired and receiving PRN opioid analgesia for pain, had a Hydrocodone/Acetaminophen order changed from 10 mg/325 mg to 5 mg/325 mg every 6 hours PRN. The MAR for the month showed both the discontinued 10 mg/325 mg order and the new 5 mg/325 mg order, and review of the controlled substance declining count sheets revealed that nurses repeatedly removed 10 mg/325 mg tablets while documenting administration of 5 mg/325 mg on the MAR, and on two occasions removed 10 mg/325 mg tablets with no corresponding MAR entry. The NP confirmed the resident should have been receiving only the 5 mg/325 mg dose during this period, and the DON stated the discontinued 10 mg/325 mg supply and count sheet should have been removed when the order was changed.
A resident with a documented Doxycycline allergy, noted in both a hospital after-care summary and the EMR allergy banner, was prescribed Doxycycline 100 mg BID for seven days after testing positive for an infectious disease. An RN texted the physician about the test result without the EMR open and entered the Doxycycline order, reporting no recall of an allergy alert. The physician, who did not have EMR access and relied on nursing staff to report allergies, was unaware of the allergy. A Guardian later identified the contraindicated order while reviewing the MAR. The DON stated nurses are expected to have the EMR open when contacting physicians, and the Administrator acknowledged that the physician ordered a medication to which the resident was allergic and that the nurse did not inform him of the allergy.
Two separate medication administration errors occurred when a nurse, distracted during a med pass, entered the wrong room and gave Adderall XR intended for a resident with ADHD to another resident with severe cognitive impairment, and in a second case, another nurse removed and administered two 50 mg Lyrica capsules at bedtime, resulting in a 100 mg dose instead of the prescribed 50 mg for a resident with diabetes and neuropathy. Both errors were discovered through review of controlled drug count sheets and MARs, and involved residents with impaired cognition who relied on staff to correctly follow physician orders.
A resident with Stage IV cancer and Stage IV kidney disease was admitted from the hospital with a discharge summary listing multiple scheduled follow-up appointments, including a PET scan and oncology and nephrology visits. The facility’s process required nursing staff to review the discharge summary and provide it to the Transportation Nurse Aide to arrange transport, but this did not occur. The family member went to the oncology appointment expecting to meet the resident, believing transportation had been arranged, but the resident never arrived and all appointments were missed. The Transportation Nurse Aide and Social Worker reported they were unaware of the appointments, and the DON confirmed the discharge summary had not been given to the Transportation Nurse Aide as expected.
A resident with hypertension and constipation had physician orders for Metoprolol and MiraLax via G-tube twice daily, scheduled for administration at 9:00 AM. On one occasion, an agency nurse fell behind on the morning med pass and did not administer these medications until around noon, outside the facility’s one-hour before/after scheduled time requirement. The nurse did not request assistance despite prior instructions for agency staff to do so if they were falling behind. The DON and Medical Director confirmed that medications were required to be given within the established one-hour window and that this expectation was not met, although the resident showed no clinical ill effects.
A resident with type 2 DM, who was cognitively intact and on insulin therapy, received a dose of glargine insulin from a pen that had been open beyond the manufacturer’s 28‑day discard date. Surveyors found an open glargine pen on the med cart labeled with an opening date that showed it was expired, as well as a second, unopened and undated pen for the same resident. The nurse who administered the insulin reported she did not check the expiration date before giving the dose and acknowledged she should have discarded the expired pen. The Pharmacy Consultant confirmed the 28‑day discard requirement, while the NP, DON, and Administrator each stated that nursing staff were expected to check med carts daily and ensure no expired medications were present or administered.
A resident with a history of stroke, epilepsy, slurred speech, and dysphagia had an order for Atorvastatin 40 mg to be given orally once daily, whole and not crushed, consistent with the manufacturer’s instructions. An agency nurse on her first shift crushed and administered the resident’s nighttime medications, including Atorvastatin, without checking the physician’s order or consulting the provider or pharmacy. The resident’s POA observed the nurse crushing the medications, informed her that the order required the tablet to be given whole, and was told the medications had already been crushed and would be withheld until the next scheduled dose if refused. The cognitively intact resident confirmed receiving the Atorvastatin in crushed form and being told it would not harm her and would not be given again until the next scheduled time if she refused it.
A resident with type 2 DM, weight gain, and varying blood sugars was started on weekly semaglutide by a PA after consultation with the medical director, but the order sent to the pharmacy lacked a specific dose. The pharmacist repeatedly notified the former DON that the order required clarification before the drug could be dispensed, yet no corrected order with dosage was provided until a new order specifying 0.25 mg was entered weeks later. During this period, nursing staff documented the drug as given or refused on the MAR despite it being unavailable on multiple dates, and the unit manager was unaware that the pharmacy needed clarification. The resident reported that the medication, intended to help regulate blood sugars and assist with weight loss, was not actually administered until weeks after it was first ordered.
A resident with chronic constipation, paraplegia, and significant contractures, who was assessed as unable to self-administer medications, was ordered Linzess 290 mcg PO daily along with Magnesium Citrate twice weekly and PRN Simethicone. Instead of administering Linzess once daily and observing ingestion, multiple nurses and medication aides routinely placed each day’s Linzess capsule into an empty Simethicone bottle kept at the bedside, then removed three capsules on certain days and left them in a medication cup for the resident to take later according to her personal bowel regimen. The resident reported and demonstrated how she self-administered the three capsules using her mouth, and surveyors observed a cup with three capsules on her bed and found a Linzess capsule stored in the Simethicone-labeled bottle. Staff interviews confirmed this practice had been ongoing for an extended period, that the MAR was signed as if Linzess had been given daily as ordered, and that there was no provider order authorizing the altered dosing schedule or self-administration.
Two residents received medications prescribed for other residents when agency nurses failed to verify the correct recipient during medication passes. In one case, a cognitively intact resident with multiple chronic conditions was given his roommate’s bedtime medications, including metformin, carvedilol, trazodone, melatonin, senna, and tizanidine, after the nurse pulled the wrong MAR and did not follow the five rights of medication administration. In the second case, a cognitively intact resident with ESRD, CAD, HTN, DMII, and COPD was given acetaminophen and buspirone ordered for another resident at a time when he had no scheduled meds, with the error identified only after a family member questioned the unexpected dosing and staff confirmed the wrong-resident administration through MAR review.
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