A resident admitted with atrial fibrillation and other conditions had physician orders for Xarelto and Amiodarone but missed multiple scheduled doses of both drugs because they were unavailable. Nursing documentation noted that one of the medications was held due to unavailability, yet there was no evidence that the provider was notified or that a medication error report was completed, despite facility policy defining unavailable medications as medication errors and requiring timely reporting to the DON or administrator. The NHA later stated they were unaware of the missed doses and that the expectation would have been to contact the physician for further orders.
The facility failed to ensure accurate and continuous administration of critical medications, including antirejection agents, an anticonvulsant, and warfarin. A resident with kidney and pancreatic transplants went without prescribed Mycophenolate Mofetil for over a month and Tacrolimus for several days due to breakdowns in communication and follow-through between facility staff and the pharmacy, leading to significant anxiety, fear, and depression for the resident. Another resident missed several days of ordered Lacosamide for seizure prophylaxis when the drug was repeatedly documented as not available or pending delivery. A third resident did not receive warfarin according to hospital discharge instructions, instead receiving a higher, variable dosing schedule, and a fourth resident received a double dose of warfarin when a previous order was not discontinued. These events were cited as significant medication errors, with one resident experiencing actual psychosocial harm and others placed at risk for more than minimal harm.
A resident with an infected prosthetic knee joint and intact cognition was ordered IV vancomycin every 12 hours for several weeks following hospital discharge. Facility policy required medications to be given as ordered and any withheld or late doses to be documented with a reason. Instead, the MAR showed vancomycin scheduled at non–12-hour intervals, multiple doses marked as not administered without any progress notes, and a total of 17 days when doses were given at intervals shorter or longer than every 12 hours. Later, when the dose was adjusted and continued per infectious disease consult, the order in the MAR ended prematurely, causing a scheduled PM dose not to be given because no active order was present. Nursing staff could not recall specific reasons for the missed doses and believed they were related to lab timing, while the DON was unaware of the extent of the missed or undocumented doses.
An LPN administered metoprolol to a resident who did not have an order for it; the medication belonged to the resident's roommate. Surveyor observation and MAR review confirmed the wrong-drug, wrong-resident error, and the DON identified it as a significant medication error. The resident had vascular dementia and severe cognitive impairment.
Medication Administration Error with PEG-Tube Bowel Regimen: An LPN did not administer a resident’s ordered Metamucil bowel regimen correctly through a PEG tube. The resident, who had dysphagia, ALS, pneumonitis due to inhalation of food and vomit, and hemiplegia/hemiparesis after cerebral infarction, was ordered Metamucil mixed with 4 to 8 oz of water, but the LPN used only 30 cc, did not stir the medication, and discarded most of the clumped dose. The LPN stated he was unaware of the water requirement and had not been giving extra water as ordered.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
A resident with Parkinsonism had ordered Carbidopa-Levodopa 25-100 mg TID with specific timing instructions, including administration one hour prior to meals and within one hour of scheduled times, yet the MAR showed at least 32 doses given late, some by several hours. Facility policy required timely administration, documentation of medication errors, and reporting to the physician and resident, but the DON reported that staff likely were not completing medication error reports. The resident voiced concerns about not receiving medications on time and subsequently began self-administering medications, while the DON acknowledged ongoing issues with medication administration timing.
A resident with facial cellulitis and intact cognition was prescribed oral clindamycin TID after an ER visit, but the facility failed to administer five ordered doses because the medication was not available from the pharmacy and was not in contingency stock. The MAR documented three missed doses on one day and two the next, with the first dose given later that second day. The physician was not notified of the missed doses. During this time, the resident’s facial cellulitis became more painful, leading to repeated hospital transfers where an MRSA cheek abscess with preseptal cellulitis was diagnosed and treated with irrigation, debridement, IV antibiotics, wound packing, and additional oral antibiotics.
A resident with type 2 DM on a prescribed sliding scale insulin lispro regimen did not receive two ordered insulin doses when blood glucose readings required administration. Facility policy required blood sugar monitoring and sliding scale insulin per MD orders. On two separate occasions, blood glucose values fell within the range requiring 2 units of insulin, but no insulin was given. One missed dose occurred when a nurse became occupied with another resident’s fall and forgot to administer insulin, and the other occurred when a med tech failed to report the blood sugar result to the nurse, resulting in the nurse not giving the ordered dose.
Two residents with serious infections did not receive multiple ordered IV antibiotic doses due to issues such as delayed PICC placement and pharmacy non-availability, and staff did not document timely physician notification of these missed doses. One resident with osteomyelitis and multiple pressure ulcers missed doses of ceftriaxone and vancomycin when the PICC line was not yet placed and medications were not available, with MAR codes indicating held or other but no record of provider contact. Another resident admitted with sepsis, cellulitis, and a history of MRSA missed several scheduled doses of IV cefazolin attributed to pharmacy issues, later sought ED care after expressing concern about going without antibiotics, and the DON acknowledged that the provider was not contacted until after multiple doses were missed, with no clear documentation of the notification in the record.
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