Significant Medication Error Leads to Resident's Death
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, Resident #2's orders for Fentanyl were erroneously changed from being administered every 3 days to being administered daily. As a result, Resident #2 was administered Fentanyl patches daily for three consecutive days, contrary to the prescribed order of every 72 hours. This error had the potential to cause serious adverse outcomes, including overdose and death, placing Resident #2 in Immediate Jeopardy. Resident #2 was admitted with multiple diagnoses, including Rheumatoid Arthritis, Pain Unspecified, and Type 2 Diabetes. The resident had a Brief Interview for Mental Status score indicating no cognitive impairment. The medical record revealed that the resident had a physician's order for Fentanyl patches to be applied every 72 hours. However, due to a transcription error, the order was entered into the facility's electronic system as a daily administration. This error was not caught by the nursing staff, who administered the patches daily. Interviews with the Director of Nursing, Nurse Practitioner, and Licensed Practical Nurses revealed that there were multiple points where the error could have been identified and corrected. The NP stated that the intention was to increase the Fentanyl dosage but maintain the 72-hour interval. However, the order was incorrectly entered into the electronic system and not questioned by the verifying nurse. The LPNs involved admitted to noticing the discrepancy but failed to clarify the order with the NP or DON. This series of actions and inactions led to the inappropriate administration of the medication, ultimately resulting in the resident's death.
Removal Plan
- A Medical Record review was conducted by the Director of Nursing to identify residents who have active orders for Fentanyl Transdermal patches to ensure the order was transcribed correctly.
- An audit of medications in the medication carts was conducted by the Clinical Interdisciplinary Team (IDT) to ensure the labels on the medication cards match the order in Matrix Care.
- A root cause analysis was conducted by the Clinical Interdisciplinary Team.
- The Nurse Practitioner was educated by the Signature State Care Consultant and the Director of Nursing on Order Entry in Matrix Care.
- The Nurse Practitioner attended an on-line Matrix Care Provider Training.
- The Director of Nursing educated the Unit Manager #2 to ensure the order is transcribed accurately and clarify any discrepancies with the provider before verifying the order.
- Unit Managers #1, #2, and #3 and licensed nurses were educated to verify orders for accuracy before activating them and to clarify any discrepancies with the providers.
- All licensed staff were educated by the Director of Nursing to ensure the label on the medication card matches the medication order in MatrixCare and to call the provider to clarify any discrepancies.
- An Ad Hoc QAPI was held with the Leadership Team and Medical Director to discuss the incident, the investigation outcome and discuss the Plan of Correction.
- The DON or Unit Manager will verify the medication card labels match the order in Matrix Care for 5 days per week for 1 week then, 3 times per week for 3 weeks then, 1 time per week for 1 month.
- A pharmacy nurse consultant will audit all medication carts to ensure the labels on the medication cards match the order in MatrixCare until the QAPI team determines compliance.
- Findings of audits will be reported to the QAPI Committee which consists of the Administrator, Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, Maintenance Director, Dietary Manager, Life Enrichment Director, Rehab Manager, and Medical Director.
- QAPI meetings will be held weekly for 4 weeks, then 2 times per month for the next 30 days, then monthly thereafter until the QAPI Committee determines substantial compliance.
- Regional oversite has been in place daily since the date Misappropriation of Resident Property was reported to Health Facilities Commission regarding Transdermal Fentanyl Patches.
- The Senior (Sr.) Signature State Care Consultant has been in the facility assisting with interviews, audits, education, process changes, attending QAPI meetings, and oversight of compliance with process changes.
- Regional oversite has occurred onsite or by phone from the Sr. State Signature Care Consultant, the Regional President of Clinical Operations, or the Regional President of Operations.
- The Regional team has collaborated with the facility team on process changes and attended Ad HOC QAPI meetings via phone to discuss audit findings and develop a plan of correction.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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 resident with hemiplegia and hemiparesis following a cerebral infarction was given another patient’s medications when a nurse failed to follow established medication administration procedures. The resident’s EHR documented that the Unit Manager was notified of a med error and that the resident received multiple medications not prescribed for him, including Tylenol, furosemide, spironolactone, olanzapine, Entresto, Brilinta, metoprolol, aspirin, ticagrelor, venlafaxine, and gabapentin. The DON stated that RNs are trained to use two identifiers and follow the facility’s Medication Administration policy, which requires verifying the resident by photo in the MAR and matching the medication source to the MAR for name, drug, dose, route, and time, but these steps were not followed in this instance.
A resident received an incorrect higher dose of Divalproex DR after the pharmacy dispensed 500 mg tablets labeled to be given multiple times daily, which did not match the physician’s order for 250 mg tablets. Nursing staff did not detect the discrepancy between the MAR and the medication card despite facility policy and expectations to verify the right dose and ensure orders matched dispensed medications. Over time, the resident developed weakness and altered mental status, was sent to the hospital at the family’s request, and was found to have an elevated valproic acid level, with hospital documentation indicating motor weakness was possibly medication-induced.
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
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 resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Failure to Follow Antihypertensive and Vasodilator Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for antihypertensive and vasodilator medications for a resident with hypertension, congestive heart failure, and coronary artery disease. The resident had an order dated 12/13/25 for Clonidine 0.2 mg every 12 hours as needed for systolic blood pressure greater than 180 or diastolic blood pressure greater than 90. The Medication Administration Records (MARs) for December 2025 and January 2026 showed multiple instances of significantly elevated blood pressures, including readings such as 248/100, 210/87, 235/101, 231/90, 187/88, and 212/87, documented by nursing staff. Despite these readings meeting the ordered parameters for as-needed Clonidine, there was no documentation that Clonidine was administered on those dates, nor was there any documented clinical rationale for withholding the medication in the nursing progress notes. Interviews with nursing staff revealed a lack of awareness and follow-through regarding the as-needed Clonidine order. One nurse stated she had not been assigned to the resident for a while prior to recording the elevated blood pressures, and another nurse reported she was not aware that the resident had an order for as-needed Clonidine for elevated blood pressure. When later contacted, that nurse declined to comment further on the medication issue that occurred in January. The Nurse Practitioner confirmed that the as-needed Clonidine was ordered for a reason and that the blood pressure parameters should have been followed, with the medication administered when indicated. The facility also failed to follow hold parameters for Isosorbide Mononitrate extended release 60 mg, ordered on 4/6/26 to be given once daily for angina with instructions to hold the medication if systolic blood pressure was less than 120. The April 2026 MAR showed that the medication was administered on multiple occasions when the resident’s systolic blood pressure was below 120, including readings of 112/76, 118/70, and 118/75, with no documentation or clinical justification in the nursing progress notes for giving the medication despite the hold parameters. A nurse involved stated she had not held the Isosorbide Mononitrate and did not realize the medication had hold parameters, explaining that the hold parameters were not noticeable on the electronic MAR and were therefore overlooked. The resident, who had moderately impaired cognition per a quarterly MDS, reported being on blood pressure medications but did not know which ones or their schedule, and described experiencing headaches and dizziness at times. The Nurse Practitioner and the DON both stated that ordered parameters for these medications should have been followed by the nursing staff.
Medication Error Involving Administration of Another Resident’s Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a nurse administered another resident’s medications. The affected resident is an adult male with hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, receiving Intermediate Care Facility level of care. A complaint was filed with the Office of Health Care Assurance alleging that the resident had been given another patient’s medications. Review of the resident’s electronic health record showed a progress note documenting that the Unit Manager was notified that a nurse made a medication error and that the resident was given another patient’s medications. The record specified that the resident received multiple medications not prescribed for him, including Tylenol, furosemide, spironolactone, olanzapine, Entresto, Brilinta, metoprolol, aspirin, ticagrelor, venlafaxine, and gabapentin. During an interview, the DON confirmed that RNs are trained and instructed to identify residents using two identifiers (name and date of birth) at all times. Review of the facility’s “Medication Administration” policy, revised 03/01/26, showed that staff are instructed to identify the resident by photo in the MAR, review the MAR to identify the medication to be administered, and compare the medication source to verify resident name, medication name, form, dose, route, and time. Despite these policies and training, the nurse did not follow the required resident identification and medication verification steps, resulting in the administration of another resident’s medications.
Significant Medication Error From Incorrect Divalproex Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to incorrect dosing of Divalproex DR. Clinical record review showed that the resident was being seen repeatedly by advanced practice providers in June for muscle weakness and weakness. A nurse practitioner documented on 6/23/25 that the resident’s weakness was found to be due to an incorrect medication dose being dispensed, noting a 500 mg dose instead of the ordered 250 mg. The physician’s order specified Divalproex DR 250 mg tablets, but the medication dispensed and administered was Divalproex DR 500 mg. Pharmacy records and interviews confirmed that on 5/18/25, the pharmacy dispensed 150 tablets of Divalproex DR 500 mg with a label instructing staff to give two tablets in the morning and three at bedtime, which did not match the physician’s order for 250 mg tablets. Nursing staff interviews indicated that nurses were expected to follow the facility’s medication administration policy, including verifying the right resident, right medication, right dose, and ensuring the medication card matched the MAR. The DON and multiple LPNs stated that if the pharmacy sent the wrong medication or if the milligrams did not match the MAR, nurses were expected to identify and correct the discrepancy, but this did not occur in this case. On 6/20/25, the resident was assessed by an LPN who initially stated she did not observe changes in condition, but her documentation reflected that the resident had altered mental status, and the resident’s mother requested hospital transfer. At the hospital, the discharge summary indicated that the resident’s motor weakness was possibly medication-induced, and lab results showed a valproic acid level of 115, above the normal range of 50–100. A physician assistant interviewed later confirmed that increased doses of Divalproex DR can cause drowsiness, muscle weakness, skin reactions, somnolence, nausea, and vomiting. These findings collectively demonstrate that the resident received an incorrect, higher dose of Divalproex DR over time, constituting a significant medication error that resulted in harm.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
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