A resident with hypertension, CHF, and CAD had repeated episodes of markedly elevated BP that met parameters for PRN Clonidine, yet nursing staff did not administer the medication or document any clinical rationale for withholding it. The same resident also received Isosorbide Mononitrate despite ordered hold parameters requiring the drug to be withheld when systolic BP was below a specified threshold, with no justification documented. Nursing staff interviews revealed lack of awareness of the PRN order and the hold parameters, while the resident, with moderately impaired cognition, reported being on BP medications and experiencing headaches and dizziness at times.
A cognitively intact resident with end stage renal disease, GI hemorrhage, and anemia had ordered medications including Velphoro, sucralfate, and midodrine, but surveyors observed four medication cups containing these drugs left unattended on the bedside table while the assigned medication aide was at the cart and unable to see the resident. The aide confirmed the medications belonged to the resident, stated they must have been left from a prior shift, and acknowledged she had not yet given that morning’s doses and that staff are expected to observe residents swallowing medications. A nurse from the previous shift also denied intentionally leaving medications at the bedside but agreed this practice was inappropriate. The resident reported that nurses often left medications at the bedside without always informing him he was expected to take them. The physician stated that failure to receive these medications as ordered had the potential for significant adverse effects, and both the unit manager and DON stated that medications were not to be left at the bedside and that residents must be assessed before any self-administration is allowed.
A resident receiving hospice and end-of-life care with severe cognitive impairment and total dependence for ADLs had an order for morphine 20 mg/ml, 0.25 ml q4h PRN for pain and shortness of breath. After a family member reported apparent pain, a medication aide assessed the resident as restless, retrieved the morphine, and administered 2.5 ml instead of the ordered 0.25 ml, documenting this on the narcotic record. Routine narcotic shift-change counts did not detect the error, and it was discovered two days later when a nurse compared the ordered dose to the previously documented administration. Subsequent assessments by hospice nursing, the DON, and an NP found the resident resting comfortably with warm, dry skin, normal chest rise, and no signs of respiratory distress, while also noting a gradual decline consistent with end-of-life status.
Three residents experienced significant medication errors due to failures in medication availability, order transcription, and timely implementation of dose changes. One resident with chronic osteomyelitis missed multiple consecutive doses of doxycycline when several nurses documented the drug as unavailable and did not promptly secure it from the pharmacy. Another resident with depression and Parkinson’s disease received 15 mg of mirtazapine nightly instead of the intended 7.5 mg after the DON mis-entered the order and the facility’s two-step verification process was not completed. A third resident with pruritus continued to receive hydroxyzine 25 mg three times daily because a physician-approved dose reduction to twice daily, identified in a pharmacist’s medication regimen review, was not promptly entered into the EMR, and the higher-frequency dosing continued until the DON eventually updated the order.
A resident with ESRD on hemodialysis, chronic respiratory failure, COPD, and moderate protein-calorie malnutrition had multiple ordered medications, including phosphate binders, Carvedilol, and Sertraline. Review of MARs showed that these medications were repeatedly not administered when the resident was out of the building for dialysis, and they were not given upon return. The care plan did not address medication administration on dialysis days or medication availability. The dialysis dietician/NP reported uncontrolled phosphorus levels and believed the facility was not giving the phosphate binder as ordered, while the unit manager acknowledged that medications were routinely held during dialysis days without notifying the Medical Director or on-call provider, contrary to the DON’s stated expectations. The Medical Director confirmed he had not been informed of the missed doses and that medication times could have been adjusted.
A resident with intractable epilepsy and moderately impaired cognition had physician orders and a care plan directing scheduled anti-seizure medications via G-tube to be given at specific morning times. On one morning, an agency nurse fell behind on medication administration and did not give the resident’s 8:00 AM and 9:00 AM anti-seizure doses until shortly after noon, 3–4 hours late and outside the facility’s one-hour before/after policy window, and did not request assistance despite prior instruction that agency staff should do so if behind. Review of the MAR, interviews with the nurse, DON, and Medical Director, and the resident’s record confirmed the delay and that the medications were not administered as ordered, although the resident showed no documented clinical ill effects.
A resident with type 2 DM and intact cognition had physician orders for scheduled Humalog, sliding-scale Humalog Kwikpen, and daily Lantus, with the care plan directing staff to provide diabetic meds as ordered. Review of the MAR for one month showed numerous blank entries where insulin doses were neither signed as given nor refused for all three insulin orders. The resident reported frequently having to ask staff about insulin injections. Multiple MAs stated they could not give insulin and had to find an RN or LPN, with no specific nurse assigned to insulin administration, and various nurses and leaders confirmed the MAR blanks and could not recall who administered the insulin on those dates. The physician expected insulin administration to be documented and, after reviewing the record, found no ill effects and blood glucose values at baseline, but the missing documentation of insulin administration remained unresolved.
A resident with COPD and bipolar disorder did not receive newly ordered Divalproex, Olanzapine, and Trelegy Ellipta for several days because the medications were not available and remained "on order" from the pharmacy. Multiple nurses documented on the MAR that these medications were not administered on several consecutive days, citing that they were on order. The resident reported lacking his inhaler and some other medications for the first few days after admission. A nurse practitioner documented that the resident had missed doses of Trelegy, Valproic Acid, and Olanzapine and stated that interruption of these medications could cause mood instability, increased behaviors, and breathing issues, and that the medications should have been administered as ordered.
A resident with DM II had a physician order for Novolog 10 units SQ with meals, to be held if blood sugar (BS) was less than 150, yet a nurse documented multiple BS readings below 150 and still administered the full insulin dose on several mornings. The nurse later reported she did not recall any BS parameters for the insulin and believed such parameters would appear on the electronic MAR. The resident was cognitively intact and regularly received insulin injections, while the NP, DON, and Administrator all acknowledged that insulin should be administered according to ordered parameters and that giving insulin outside those parameters constitutes a serious medication error.
A resident with Parkinson’s disease, failure to thrive, severe malnutrition, and psychosis exhibited escalating aggression despite non-pharmacological interventions. An NP gave a verbal order for Haldol 2 mg IM for agitation, but a unit manager nurse did not repeat back or verify the dose and instead retrieved four 5 mg/mL vials from the emergency supply and administered a total of 20 mg IM. The nurse initially reported the 20 mg dose to colleagues without it being questioned, only recognizing the tenfold error later while entering the written order into the record. The DON later identified the lack of read-back of the verbal order as a key process failure contributing to this significant medication error.
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