A resident with COPD, diabetes, heart failure, and depression had multiple scheduled medications and continuous O2 at 3 L/min ordered for the evening shift, but an RN did not administer the 4 PM, 8 PM, or 9 PM doses and did not ensure the resident received ordered oxygen, nor did the RN notify a supervisor or MD of the missed doses. The RN assumed the resident was with a visitor, did not verify the resident’s return, and only began looking for the resident later in the shift. The resident was ultimately found on the floor unresponsive without O2 in place, CPR was initiated, EMS assumed care, and the resident was pronounced deceased. Supervisory staff and the MD reported they were not informed during the shift that the resident was missing or that medications and oxygen had not been provided, and records showed no hourly safety checks or medication administration during the relevant period.
Surveyors found that the facility failed to administer medications according to provider orders and required timeframes, and failed to document or notify providers when medications were omitted or given late. Multiple cognitively intact and cognitively impaired residents with conditions such as DM, CHF, respiratory failure, seizure disorder, CVA history, osteomyelitis, and HTN had numerous blank MAR entries indicating missed doses of high‑risk medications, including insulin, anticoagulants, anti‑seizure drugs, cardiac medications, antibiotics, and controlled pain medications. One resident received duplicate and excess dosing of oxycodone due to overlapping active orders, along with frequent missed and late insulin and other scheduled medications. EHR audits showed hundreds of instances of medications administered more than one hour late for several residents, and narcotic count sheets contained missing entries. Residents reported frequent delays and missed medications, and clinical leaders acknowledged that medications were not consistently administered as ordered and that providers were not reliably notified of omissions or late administrations.
Significant medication error involving crushing of extended-release metoprolol. An LPN crushed multiple medications for a resident with HTN, HF, and DM, including an extended-release metoprolol succinate tablet labeled to swallow whole and not crush. The resident had no current order to crush medications, and the DON, physician, and pharmacist all confirmed the extended-release tablet should not have been crushed.
A resident with Parkinson’s disease, dementia, and anxiety received another resident’s potent medications, including opioids and other CNS-acting drugs, after an LPN pre-poured medications for about 20 residents and misidentified a pill, administering the wrong medication cup. Facility policy required correct resident identification and adherence to the six rights of medication administration, but the LPN’s pre-pouring and misadministration led to the resident receiving an incorrect regimen. Subsequent documentation showed hypotension, bradycardia, lethargy, and decreased respirations, with limited and delayed physician notification and incomplete nursing documentation of the resident’s changing condition, culminating in the need for Narcan as ordered by the physician.
A resident with a history of stroke and seizure disorder was ordered Vimpat 50 mg PO BID, but an incorrect 200 mg BID dose was entered into a separate e-script system and filled by the pharmacy. The eMAR continued to show a 50 mg dose, yet four LPNs administered 200 mg tablets for four doses, as evidenced by missing tablets and narcotic count signatures, while documenting 50 mg on the MAR. The DON later explained that the EMR used for orders was not linked to the narcotic e-script system and there was no reconciliation process between the e-scripted narcotic order and the physician order in the chart, leading to the resident receiving a higher-than-ordered dose.
The facility failed to ensure methadone was administered according to physician orders, resulting in significant medication errors for multiple residents on methadone maintenance therapy. Policy required nurses to use the eMAR as the source for medication administration and to verify the five rights, but methadone bottles for several residents carried doses that did not match the physician orders entered in the electronic record, despite daily administration being documented. Nursing staff reported either not cross-checking bottle dosages against orders or relying solely on the bottle label or resident familiarity, and they often did not notice discrepancies. The attending physician, DON, and medical director described a process in which the methadone clinic determined doses, nurses transcribed bottle labels or clinic information into the electronic record, and physicians signed orders without independent verification or direct clinic documentation, contributing to inconsistent and inaccurate methadone dosing information.
A resident with epilepsy and other comorbidities was readmitted from the hospital with discharge orders for carbamazepine and primidone, including specific dosing schedules. The care plan required seizure medications to be given as ordered and monitored. Due to an error during medication reconciliation after readmission, these anti-seizure medications were not entered and therefore were not administered for several days, as reflected on the MAR, until the resident experienced a seizure and the omission was discovered.
A nurse administered seven medications to a resident that were prescribed for another individual, failing to verify the resident's identity and not following the required medication administration protocols. The resident, who had dementia and severe cognitive impairment but could usually state their name, received the wrong medications due to the nurse's failure to perform the five rights of medication administration.
Surveyors found that three residents experienced significant medication errors, including missed doses of prescribed medications after hospital discharge and improper insulin administration outside of ordered parameters. Two residents with diabetes received insulin without appropriate blood glucose checks or despite low glucose levels, and another resident did not receive any prescribed medications or treatments for several days after returning from the hospital. Staff interviews confirmed that these actions were not consistent with physician orders or facility policy.
A resident with epilepsy and dementia missed five doses of Lamictal due to unavailability, and multiple LPNs failed to notify the physician or supervisor as required. The resident subsequently experienced a breakthrough seizure and was hospitalized. The facility's policy for reporting medication administration issues was not followed.
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