A resident with multiple chronic pain-related conditions and intact cognition had an order for tramadol 50 mg five times daily at specific times, with facility policy allowing only a one-hour window around scheduled doses. Review of the eMAR showed repeated late administrations, including doses given more than two to three hours past the ordered times and two morning doses given together, causing doses to be closer together than prescribed. The resident and her daughter reported that medications were not given on time and sometimes too close together, and the resident described intermittent extreme fatigue and difficulty staying awake. A nurse practitioner documented increased fatigue, and the DON confirmed that the opioid medication had been administered outside the facility’s policy time parameters.
A resident with multiple chronic conditions, including type II DM, heart failure, and kidney failure, experienced significant medication errors when two nurses administered Novolog 10 units twice due to failure to document on the MAR, and on another occasion an LPN gave the resident a full set of medications intended for the roommate, resulting in wrong-resident and wrong-medication administration. Staff interviews confirmed the errors, and facility policy and a QMA’s statements indicated that proper resident identification and adherence to the five rights of medication administration were required but not followed.
Two residents received each other’s bedtime medications after an RN set up their medications in cups and mixed them up, despite one resident questioning the unusually high number of pills. One resident with diabetes, chronic kidney disease, and vascular disease received multiple psych, GI, and other medications instead of his ordered carvedilol, fenofibrate, gabapentin, and oxycodone, while the other resident with cerebral palsy, dementia, and psychiatric diagnoses received those medications instead of his ordered regimen. The facility’s medication administration policy, which required verifying orders, checking labels and doses against the MAR, and confirming resident identity, was not effectively followed, resulting in this significant medication error.
A resident with dementia and osteoporosis was given another resident’s evening medications when a QMA, distracted while using a medication cart for the first time, mixed up two cups of pills for residents in nearby rooms and failed to follow the facility’s five-rights medication policy. The resident, who was ordered cholesterol and dementia medications at bedtime, instead received another resident’s seizure and diabetic medications, and a family member also reported that staff had previously attempted to perform a blood sugar test on this non-diabetic resident that was intended for a different patient.
A resident with heart disease, heart failure, obesity, and atrial fibrillation was admitted from a hospital with an order for metoprolol tartrate 25 mg, 0.5 tablet BID, but the order was incorrectly transcribed into the facility MAR as 25 mg, 1 tablet BID. The resident consequently received four double-dose administrations of metoprolol before becoming short of breath during therapy, with documented hypotension and bradycardia that led to EMS transport and hospital observation. An RN later confirmed the transcription error, and staff described an admission checklist for verifying transfer orders and medications that was available but not required or incorporated into the resident record, despite a facility policy requiring accurate and careful transcription of physician orders.
Surveyors found that a QMA routinely crushed and mixed multiple oral medications in applesauce for two residents, including memantine, aspirin EC, and potassium ER, despite pharmacy guidance and reference materials indicating these products should not be crushed. One resident had vascular dementia and swallowing difficulties, while the other had a history of stroke and vascular dementia without a swallowing disorder. The QMA reported she always crushed all medications for these residents, either due to swallowing problems or to improve acceptance. Although the facility had a General Dose Preparation and Medication policy requiring adherence to pharmacy guidelines and a pharmacy-supplied “do not crush” list, there was no formal, specific policy on crushing medications, and the listed non-crush medications were still altered during administration.
Three residents with diabetes did not receive insulin in accordance with physician orders or manufacturer instructions. Insulin was often administered after meals instead of before, and staff did not consistently notify providers of high blood sugar readings or update care plans. Nursing staff cited workload and resident availability as reasons for delayed or improperly timed insulin administration, leading to significant medication errors.
A resident with complex medical needs, including end-stage renal disease and a history of medication allergies, was given another resident's morning medications in error. The resident did not receive their own prescribed medications, and the error was confirmed by staff and family interviews. The facility's medication administration policy, which requires verification of the five rights and resident identification, was not followed, leading to the error.
A resident was administered multiple medications in error after admission due to a failure in the medication transcription and verification process. An LPN transcribed the wrong medication orders, and the required second nurse check was not performed, resulting in the resident receiving 23 doses of 11 different medications not prescribed for him over several days. The error was discovered only after a review of records, despite concerns raised by the resident's family.
Two residents did not receive prescribed medications for infections and COVID-19 as ordered, including missed doses of IV antibiotics and Paxlovid, with no documentation or explanation for the omissions. Facility staff were unable to account for the missed administrations, and there was a lack of follow-up or communication regarding the errors.
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