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 with atrial fibrillation and a dislocated knee had apixaban ordered to be held before orthopedic surgery, but the anticoagulant was still administered instead of being withheld. Staff later discovered the error, notified the surgical team, and the surgery was postponed. Interviews confirmed confusion about the hold order and that the medication was not properly removed from the med cart.
A resident with intact cognition and multiple diagnoses, including Parkinson's disease and depression, was prescribed lorazepam. An LPN failed to sign out a controlled dose when first administered, later assumed the dose had not been given, and administered a second dose, resulting in a double dose of lorazepam. The medication error, including assessment and follow-up, was not documented in the EHR, despite facility policy requiring documentation of medication errors and monitoring for adverse effects.
A resident with end-stage COPD and on hospice care had an order for Morphine Sulfate 10 mg/5 ml, 1 ml (2 mg) PO q4h PRN for air hunger, but the pharmacy dispensed Morphine 20 mg/ml with labeling that directed 1 ml (20 mg) q4h PRN. Nursing staff accepted and administered the medication without verifying the concentration against the original order, relying instead on the bottle label, narcotic record, and an EMAR entry that only specified 1 ml without the milligram dose. An LPN gave one 20 mg dose for labored breathing and pain, and an RN later administered two additional 20 mg doses for air hunger, while another RN acknowledged that the usual two-nurse verification process at receipt was not followed. The ARNP and pharmacist later confirmed that the pharmacy had entered and dispensed the wrong concentration, and that the resident had received three doses at ten times the ordered amount, constituting a significant medication error.
Multiple medication administration failures occurred, including missed doses, wrong medications, and delayed tube feedings for several residents. A cognitively intact resident with complex cardiac, respiratory, and neurologic conditions had repeated omissions of seizure medications, Parkinsonism medication, tube feeding, nebulizer treatments, eye drops, nasal spray, and other ordered drugs. A resident with severe cognitive impairment and eye disorders received ear drops in the eye instead of prescribed ophthalmic medications. Another cognitively impaired resident was given another resident’s antihypertensives, potassium, anxiolytic, and gastrointestinal medication after an LPN relied on a nod for identification. A cognitively intact resident with chronic pain and cardiac conditions did not receive a scheduled morning Tramadol dose and later reported significant pain. The DON reported that staff were expected to follow the five rights of medication administration per facility policy.
Two residents did not receive ordered medications as prescribed. One resident with severe cognitive impairment and multiple comorbidities had an admission order for daily furosemide, but the drug was omitted from the MAR and never administered after the facility returned the delivered medication to the pharmacy, with no evidence of discontinuation. Another resident with intact cognition and serious medical conditions had an order for daily zinc sulfate, which was documented as unavailable for several days due to a backorder, and there was no documentation that staff notified the pharmacy to obtain the medication from an alternative source. The facility’s medication administration policy lacked a defined process to verify accurate transcription of new admission orders.
A resident with complex cardiac and pulmonary conditions and severe pain had PRN orders for Tylenol, hydrocodone‑acetaminophen, oxycodone for moderate to severe pain, and hydromorphone for severe breakthrough pain only at a pain level of 10. Despite black box warnings and clear parameters, MAR review showed repeated concomitant administration of multiple opioids and frequent use of hydromorphone when documented pain scores were below 10. A CMA with limited experience administered PRN opioids without guidance on differentiating moderate versus severe pain and acknowledged not following the hydromorphone order, while an RN reported giving all three opioids together at the resident’s insistence. Facility policies and the CMA job description prohibited CMAs from administering PRN medications and required adherence to physician orders, but these were not followed, and the resident was later hospitalized with acute hypoxic respiratory failure and acute on chronic CHF.
The facility failed to prevent significant medication errors by allowing residents without self-administration orders to take medications on their own and by preparing and passing medications to multiple residents at the same time. One resident with intact cognition was found with pills left at the bedside and reported that staff routinely left medications for self-administration without observation. Another cognitively intact resident with anemia, HTN, heart failure, renal insufficiency, and seizure disorder received a roommate’s medications after an LPN prepared and delivered both residents’ medications simultaneously and did not observe ingestion, resulting in the resident consuming Simvastatin, Gabapentin, and oxybutynin in error and experiencing documented changes in mental status, thirst, and sleepiness. Staff interviews and facility policy confirmed that these practices violated established requirements to administer medications to one resident at a time, verify identity, observe ingestion, and avoid leaving medications at the bedside without a self-administration order.
A resident with moderate cognitive impairment and seizure disorder experienced significant medication errors involving anticonvulsants. The MAR showed Cenobamate was documented as given even when it was unavailable for multiple days, and staff did not document contacting the pharmacy about the missing medication. The resident also received incorrect doses of Clobazam and Lacosamide because of admission transcription errors, which the pharmacy consultant later identified.
Medication Error and Lack of Post-Error Assessment: An RN was interrupted during med pass and then gave one resident another resident’s bedtime meds, including an antipsychotic, an anxiolytic, and a statin. The resident, who had MDD and anxiety and intact cognition, later reported visual hallucinations, but the record lacked documentation of a post-error assessment or vital signs, and the RN confirmed she did not check them.
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