A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
A nurse’s transcription error led to a Farxiga order, intended for one resident, being entered into another resident’s chart, causing that resident—who had diagnoses including edema and hypokalemia—to receive Farxiga 5 mg daily for an extended period before the mistake was discovered. The issue came to light following a community complaint and was confirmed through record review, a Medication Error Form, staff statements, and an interview with the DON, all documenting that the incorrect medication was administered for many days.
A resident with ESRD and gastritis had orders for dialysis and scheduled doses of Auryxia and Pentasa, but MAR review showed repeated missed 8:00 AM doses on dialysis days. The record did not show that the MD was notified, and the ADNS acknowledged Auryxia was not being given at the facility while the dialysis center confirmed it did not administer Pentasa during treatments.
A resident with CHF, afib, moderate cognitive impairment, and low body weight was mistakenly given another resident’s clozapine 150 mg and melatonin 3 mg by a CMT who entered the wrong room and failed to verify identity, contrary to facility policy requiring multiple resident-identification checks. The resident did not receive ordered warfarin and metoprolol during this pass. Subsequently, the resident was found unresponsive with abnormal respirations, tachycardia, and hypoxia, required EMS intervention with suctioning, high-flow oxygen via BVM, and IV emergency cardiac medication, and was admitted to the hospital with altered mental status, profound hypothermia, pleural effusion, and aspiration pneumonia, later transitioning to comfort care and expiring. The DON was unable to show the resident was kept free from significant medication errors, and the Medical Director stated she expected correct medications to be given to the correct resident.
A resident receiving warfarin for atrial fibrillation and HF experienced a significant med error when a PT/INR result was not reported to the physician in a timely manner, resulting in a missed warfarin dose. The record also showed a later ordered PT/INR was not documented as obtained as ordered, and the UM acknowledged both the missed dose and the delayed reporting.
A resident with Alzheimer's disease and cardiac comorbidities was actively dying and experiencing increased pain and agitation when a hospice RN recommended more frequent scheduled and PRN Morphine and Ativan for end-of-life comfort. An RN texted these recommendations to the physician, who approved them, but the new orders were never entered on the MAR or implemented. As a result, only the prior, less frequent PRN and TID Lorazepam and PRN Morphine orders remained active, and the last doses of Ativan and Morphine were administered many hours before the resident's death. The physician later stated the nurse should have implemented the hospice recommendations, and the DON acknowledged the resident did not receive the comfort medications as ordered.
A resident with a history of orthostatic hypotension and autonomic nervous system disorder was inadvertently given another resident’s medications during a morning med pass while an RN was training a newly hired LPN. The RN prepared multiple drugs intended for a roommate with Parkinson’s disease, DM, HTN, CAD, and depression, including two antihypertensives, an antidiabetic, an antiplatelet, an antiparkinsonian agent, an antidepressant, and vitamins, and handed them to the LPN to administer. The LPN entered the shared room, identified both residents, but administered the prepared medications to the wrong resident, then later disclosed the error when returning with the correct medications. Following the error, the affected resident’s BP progressively dropped, the resident became pale and weak, and was transferred and admitted to the hospital with hypotension, as confirmed by hospital records and acknowledged by the DON.
A resident admitted with a UTI had hospital discharge orders and corresponding facility orders for Meropenem 1 g IV in 50 mL NS three times daily for several days, but three doses were missed. Nursing staff did not administer the antibiotic despite Meropenem and 100 mL NS being available in the IV E‑kit, stating they believed they could not give the medication without a 50 mL NS bag and did not contact the pharmacy for clarification. E‑kit utilization records showed no Meropenem or NS was removed, and documentation did not show that a provider was notified of the missed doses. The resident was later transported to the hospital, where they were found to have hypercarbic hypoxic respiratory failure, sepsis, and influenza, and subsequently died after being placed on comfort measures.
A resident with a history of opioid addiction and other medical conditions did not receive prescribed Methadone for two days due to the medication being unavailable. The DON reported delays in obtaining the medication from the treatment center, and the resident exhibited behavioral changes during this period. The facility could not demonstrate that the resident was kept free from significant medication errors.
A resident with multiple medical conditions did not receive any of the 17 ordered doses of Insulin Lispro over several days, as confirmed by MAR review and staff interviews. This omission led to persistently elevated blood glucose levels, clinical decline, and eventual transfer to an acute care hospital. Facility policy required insulin administration as ordered, but no evidence was provided that the medication was given.
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