The facility failed to prevent significant medication errors when an antipsychotic injection order for a resident with schizophrenia was mis-transcribed in the EMR, causing multiple haloperidol decanoate injections to be given within a short period instead of once every 21 days, despite an LPN questioning the order and being instructed by a supervisor to administer it as written; the resident’s family and therapy staff later observed increased tremors, confusion, and functional decline. Another resident with schizoaffective disorder had a scheduled haloperidol decanoate injection documented as refused, but the LPN did not notify the SW, DON, or provider as required, and the injection was never re-offered, coinciding with documented behavioral decompensation, increased delusions, refusals of care, and falls. On a separate occasion, an agency LPN left mid-shift without notice and failed to pass HS medications, resulting in several residents not receiving ordered doses of antipsychotics, anti-seizure medications, opioids, a beta-blocker, and a diuretic, which the facility categorized as significant medication errors due to the potential to jeopardize health and safety.
Improper Insulin Pen Administration: An LPN administered insulin via a pen device to a resident without priming the needle after attaching it, stating priming was unnecessary because the cartridge had been used before. The same LPN again prepared an insulin dose without priming the pen, and the DON provided information that did not match the manufacturer package insert, which indicated a safety test should be performed before administration. Literature reviewed showed equivalent insulin pen manufacturers recommended priming before each use.
A resident with pain and hemiplegia experienced significant medication errors when scheduled Cyclobenzaprine (Flexeril) doses were missed because the drug was unavailable, and nursing staff did not notify the physician or obtain an alternative despite a standing order for around‑the‑clock pain management. Pharmacy records showed a 30‑day supply should have remained in use, with multiple days of doses unaccounted for, and the medication was not stocked in the backup box. During the same period, a Fentanyl patch dated several weeks earlier was found still applied to the resident’s chest even though the order for the patch had been discontinued, and the DON was unaware it remained in place. These events occurred despite facility and pharmacy policies requiring medications to be administered as ordered and procedures to address unavailable or delayed medications.
A resident with a seizure disorder and severe cognitive impairment had an order for Valproic Acid via PEG tube twice daily, scheduled for 7:30 AM and 9:00 PM. On the day in question, the morning dose was not actually given until 12:44 PM, far outside the allowed administration window, and the evening dose was not administered at all, despite MAR entries indicating it had been given. Nursing notes documented two seizures in the early morning hours following these missed and delayed doses. The DON confirmed the significant delay of the morning dose and the omission of the evening dose, in contrast to facility policy requiring medications to be given per physician orders and identifying time of administration and omission as medication error factors.
Two residents experienced significant medication errors when ordered drugs were not administered in accordance with physician orders and facility policy. A resident with diabetes had insulin doses increased and then received short‑acting insulin late and only 2.5 hours apart, without the LPN confirming pre‑meal blood glucose or food intake, despite a prior severe hypoglycemic episode that was not brought to a provider for assessment or insulin adjustment. Another resident with epilepsy missed multiple doses of Keppra and valproic acid over several days due to refusal and dysphagia, with staff documenting lethargy, poor responsiveness, inability to swallow, and seizure activity, yet there was no documented provider notification about the repeated missed antiepileptic doses until an LPN, alerted by a CNA, assessed swallowing difficulty and arranged hospital transfer. These actions and omissions conflicted with the facility’s medication administration and change‑in‑condition policies, which required timely administration, documentation, and provider notification for missed doses and acute changes.
A cognitively intact resident with chronic pain relied on a nightly oxycodone 10 mg dose for pain control. In January, the resident reported that staff ran out of her medication, had difficulty obtaining doses from the backup box, and that she did not receive her pain pill one night, resulting in pain rated 10/10 and poor sleep. Records showed the last tablet from her main supply was used, backup oxycodone was pulled on several but not all subsequent nights, and the MAR documented a held dose due to needing a new prescription. An LPN later stated she likely gave a late dose from backup but did not document it correctly, and the DON could not account for a dose documented as given on another night, concluding it appeared the resident did not receive that dose despite MAR documentation.
A cognitively intact resident with insulin‑dependent DM and other chronic conditions experienced a significant medication error when an RN administered 52 units of short‑acting Novolog instead of the ordered long‑acting insulin, resulting in wrong medication and wrong strength/quantity. Family members reported that the resident was transferred to the hospital after this large dose of fast‑acting insulin, and facility documentation, including a medication error form, nurse progress note, and physician note, confirmed the mis‑administration. The DON acknowledged that a medication error had occurred, and later observation found the resident non‑verbal and non‑responsive with hospice services in place.
A resident with a history of bipolar disorder, dementia, and delusional disorder had an order for metoprolol succinate ER 25 mg daily with instructions to hold the dose and notify the provider if systolic BP was <110 or pulse <60. Review of MARs over several months showed that nursing staff repeatedly administered metoprolol on days when documented systolic BP readings were below 110, and there was no record of provider notification when BP readings were outside the ordered parameters. In interviews, an LPN confirmed that medications with parameters should be held when vital signs are outside those limits, the PA and NP stated the metoprolol should have been held under those conditions, and the DON acknowledged that giving the medication without contacting the provider when BP was outside parameters was a medication error.
Two residents with the same first name were involved in a medication error when an LPN, working an unfamiliar assignment, entered the wrong room and administered a handful of oral medications, a chocolate nutritional supplement, and a nasal spray without using two identifiers or noting the absence of an ID bracelet. A cognitively intact resident with chronic kidney disease and recent hip fracture received another resident’s regimen, including Eliquis, Entresto, Jardiance, Lopressor, and spironolactone, in addition to his own scheduled medications, and later reported feeling lightheaded and "high." The intended recipient, a medically complex resident on IV Vancomycin with multiple cardiac and infectious diagnoses and DNR status, did not receive his prescribed doses. The facility’s policies required two-identifier verification and prohibited administering one resident’s medications to another, and its occurrence reporting policy required prompt reporting and investigation of medication-related incidents, but leadership became aware of the possible error only later in the day after staff notification.
A resident with multiple chronic conditions was given another resident’s full morning medication regimen, including insulin and cardiovascular medications, after an RN preceptor removed and documented the medications in the EHR for a different resident and then handed them to an orienting LPN who lacked MAR access. The LPN did not verify the five rights of medication administration and administered the medications to the wrong resident, while the resident’s own scheduled morning medications were held. A regional clinical consultant later identified that the person who pulled the medications was not the one who administered them and that standard professional practices and the five rights were not followed.
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