A resident with a midline IV catheter and multiple chronic conditions had several oral medications ordered to be crushed and given by mouth. An LPN instead crushed the evening doses of apixaban, gabapentin, magnesium oxide, midodrine, and potassium chloride, mixed them with water, and administered them through the resident’s midline catheter, contrary to the prescribed route and facility policy requiring adherence to the six rights of medication administration. Other staff became aware after the resident’s family questioned the practice and IV medications could not be infused through the midline. The LPN admitted to administering the oral medications via the midline, and the resident subsequently experienced low oxygen saturations and was sent to the hospital, where evaluation showed hyponatremia but otherwise stable status.
Surveyors found that the facility failed to follow physician orders for anticoagulant medications for two residents. One resident on hospice with atrial fibrillation had Jantoven orders that were not clarified, resulting in three missed doses. Another resident with a right tibia fracture, ordered to receive 70 mg of Enoxaparin daily for DVT prophylaxis, was observed receiving an 80 mg prefilled Enoxaparin injection from an LPN, who acknowledged administering the incorrect dose; the DON confirmed both medication errors.
Warfarin Administered Despite Hold Order: A cognitively impaired resident receiving warfarin for atrial fibrillation had a critical INR result, and the physician ordered the anticoagulant held for 3 days with daily INR checks. Review of the MAR showed the warfarin was still given on 2 nights after the hold order, and the DON confirmed it should have been held.
A resident, cognitively intact and on hospice care, had an order for morphine sulfate concentrate 20 mg/mL to be given as 5 mg PO q2h PRN for pain/SOB, with non-pharmacological interventions attempted first. Facility policy required adherence to the 10 Rights of Medication Administration and preparedness for opioid-induced respiratory depression. Despite this, documentation on the controlled medication record showed the resident was given 1 mL of morphine concentrate instead of the prescribed 0.25 mL. Nursing notes and an employee statement confirmed that an excess dose was administered, after which the resident developed increased lethargy and decreased BP and required two IM doses of Narcan, with subsequent improvement and return to baseline.
A transportation driver delivered an individual from dialysis who shared the same first name as a newly admitted resident expected back from treatment. The receptionist directed the driver to the resident’s room based on this information. The individual had no ID band, but staff took his photo, uploaded it to the EMR, and an RN and an LPN relied on his verbal acknowledgment of the shared first name and the new photo profile to identify him. Without confirming two identifiers or recognizing that he was not the admitted resident with ESRD and Parkinson’s disease, the LPN administered scheduled medications including Flomax, Sinemet, Vitamin D, and a multivitamin that were ordered for the actual resident. Later calls from the transport company and another facility revealed that the individual was a different resident from another facility who had been transported to the wrong location, confirming that medications had been given to the wrong person.
A significant medication error occurred when an agency RN, unfamiliar with residents and lacking clear identification procedures, administered morphine sulfate and levothyroxine ordered for one severely cognitively impaired resident to that resident’s cognitively impaired roommate, after calling out the wrong name and failing to verify identity via the electronic health record photo or another reliable method. The resident who received the wrong medications developed profound bradycardia and hypotension, was transferred to the ED with accidental opioid poisoning, and required naloxone to stabilize vital signs before returning to the facility. Surveyors also found that multiple residents lacked identification photos in the EHR despite facility policy, and staff reported relying on familiarity, resident self-identification, or room nameplates instead of a consistent, reliable process, creating a systemic breakdown in resident identification during medication administration.
A resident with bipolar disorder, anxiety, and depression had physician orders for 40 mg of Ingreeza daily for drug-induced subacute dyskinesia and for all medications to be crushed, consistent with the care plan directing pills to be finely crushed. During a medication pass, an LPN prepared the Ingreeza capsule softened in pudding and administered it without opening the capsule and sprinkling the contents, thereby not crushing the medication as ordered. In interviews, the LPN and facility leadership confirmed that the medication was not administered according to the physician order and that this constituted a significant medication error.
A resident with CHF and paroxysmal AFib was mistakenly given a roommate’s medications when an LPN entered a shared room, called out the roommate’s name, and administered the prepared medications to the other bed after that resident responded. The facility’s policy required licensed staff to verify resident identity using identifiers such as ID bands, photos, or staff confirmation, but this verification was not performed. As a result, the resident received multiple unintended drugs, including aspirin, Xcopri, Aptiom, levetiracetam, lorazepam, morphine, acetaminophen, carbidopa-levodopa, and gabapentin. The resident initially appeared stable but then developed lethargy and hypotension, leading to Narcan administration, EMS activation, and hospital transfer, where records confirmed accidental ingestion of the roommate’s medications with resultant lethargy and hypotension.
A resident admitted for rehab after knee arthroplasty with multiple comorbidities experienced significant medication errors when admission orders were incorrectly transcribed into the EMR. An RN entered the wrong antibiotic within the cephalosporin class, resulting in Cefaclor being administered instead of the ordered Cefadroxil, and also entered incorrect start dates for Aspirin and Lovenox. As a result, Aspirin 81 mg was given before the ordered start date while the resident was on Lovenox, and Lovenox was administered and discontinued outside the physician-ordered timeframe. The resident was notified of the errors, reported being upset, and experienced mild nausea but remained otherwise stable.
A resident with a history of deep vein thrombosis and dementia was ordered warfarin 2.5 mg at bedtime with a PT/INR recheck. The resident received warfarin as ordered initially, but then went several days without the medication and without the scheduled PT/INR because the staff member entering the orders signed off the lab in a way that prevented it from populating and set the warfarin order to stop on the lab date. The missed doses and omitted lab were later identified by nursing staff and brought to the provider’s attention.
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