Failure to Administer Synthroid Leads to Resident's Hospitalization
Summary
The facility failed to prevent a significant medication error for a resident with a known history of hypothyroidism and myxedema coma. Upon admission, the resident's Synthroid medication, crucial for managing hypothyroidism, was not ordered or administered from the time of admission until the resident's transfer to the hospital several months later. This oversight led to the resident's condition deteriorating significantly, resulting in a transfer to the hospital where the resident was diagnosed with acute toxic metabolic encephalopathy, likely myxedema coma, and an elevated thyroid-stimulating hormone level. The resident's medical records from the previous skilled nursing facility indicated that Synthroid had been prescribed since 2022. However, upon admission to the current facility, the medication order was not transcribed accurately by the nursing staff. The resident's medical history included severe cognitive impairment, hypothyroidism, and previous episodes of myxedema coma, yet these critical details were not adequately addressed in the resident's care plan or medication administration records. Interviews with facility staff revealed a lack of proper communication and verification processes during the resident's admission. The admitting nurse did not accurately transcribe the medication orders, and there was no evidence of the required two-nurse verification process. Additionally, the consultant pharmacist failed to identify the absence of Synthroid in the resident's medication regimen during monthly reviews, further contributing to the oversight.
Removal Plan
- Resident #150 was transferred to the hospital and did not return to the facility. The resident was subsequently discharged to an alternate facility post-hospitalization.
- The facility completed an ADHOC Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, Physician #825 (medical director), the DON, RN #937 (staff development coordinator), LPN UM #906, Admissions #969, LPN UM #860, Social Service Designee (SSD) #884, Licensed Social Worker (LSW) #820, LPN Minimum Data Set (MDS) #809, Human Resources (HR) #872 to discuss the survey concern and to develop an immediate plan of correction/action that was approved by the Medical Director.
- RN Regional #815 educated the DON and RN #937 on a new Medication Reconciliation Addendum which included two nurse verification at the time of admission, speaking directly with the provider Certified Nurse Practitioner (CNP)/physician via phone (no texting, faxing or picture taking) and included orders that were discontinued (on admission) must be noted in the admission progress notes.
- RN #937 educated 37 of 37 licensed nurses on a new Medication Reconciliation Addendum as well as transcribing physician orders and notifying the physician/CNP when a new admission/readmission entered the facility and verifying medications with two nurses and with the provider as well as entering a progress note reflecting verification of medications and any medications that were discontinued at the time of the verification. All nurses were educated prior to working their next shift.
- RN MDS #982 conducted care plan audits for all residents with diagnoses of hypothyroidism and hyperthyroidism to ensure care plans were addressed for their specific health needs. Care plans were revised and updated as needed.
- LPN UM #860 and LPN UM #906 audited all admissions/readmissions in the last two weeks to verify medications were transcribed correctly and verified with the physician/CNP timely.
- The DON completed chart audits on all residents with a diagnosis of hypothyroidism and all residents receiving Synthroid (Levothyroxine) to ensure the orders were transcribed properly, and the medications was administered as ordered.
- RN Regional #815 completed one-to-one education for the two nurses who admitted Resident #150, LPN #822 and LPN #823, on medication reconciliation to include two nurse verification at the time of admission, speaking with the provider CNP/physician via telephone (no texting, no faxing and no picture taking) and any orders that were discontinued must be noted in the admission progress note.
- Regional RN #815 educated CNP #824 and Physician #825 regarding progress notes and the need for a plan (of care) for diagnosis present in each resident's medical records.
- Regional RN #815 educated Pharmacist #840 on ensuring pharmacy reviews included all diagnoses having an appropriate plan of care in place including medications administered to the residents.
- The facility implemented a plan for the DON/designee to review CNP and physician notes weekly for four weeks to ensure the diagnosis of hypothyroidism has an appropriate plan in place.
- The facility implemented a plan for the DON/designee to review pharmacy recommendations monthly for three months to ensure residents with a diagnosis of hypothyroidism have been reviewed and have an appropriate plan of care in place to address the diagnosis of hypothyroidism.
- The DON/designee would complete daily chart audits, Monday through Sunday for three months on all new admissions/readmissions to ensure the orders were transcribed properly, medications were verified with two nurses and with the provider and the progress note entered in the medical record reflected verification of orders as well as any changes made during the verification progress. The audits would continue until compliance could be maintained for three consecutive months.
- The facility would complete weekly QAPI meetings for four weeks to review all audits regarding this action plan.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Significant morphine dose error: An RN administered 0.25 mL (5 mg) of morphine sulfate buccally instead of the ordered 0.1 mL (2 mg) dose to a resident with severe cognitive impairment, Alzheimer’s disease, CAD, and dementia. The RN said she followed the medication box label, while the unit manager confirmed the correct dose was on the EMAR. The resident was assessed afterward and remained unchanged.
An LPN administered Humalog insulin to a resident with stroke, aphasia, and diabetes without priming the insulin pen as required by manufacturer instructions. The LPN dialed the ordered 5-unit dose but did not prime the pen with 2 units before injection, and later stated she was unaware of the need to prime it. The DON confirmed insulin pens should be primed according to the manufacturer's instructions.
A resident with CHF and dysphagia had a medication error when an MA crushed and administered multiple morning meds, including Potassium Chloride ER, despite a provider order that it not be crushed. The facility policy required meds to be given as ordered and prohibited crushing do-not-crush, slow-release, and enteric-coated meds; the record also identified potassium chloride as a high-alert medication.
Two residents experienced significant medication errors when ordered meds were not available or not administered as prescribed. One resident on hospice went more than 24 hours after admission without ordered Morphine for pain and air hunger, while another resident missed multiple doses of a Lidocaine patch and Mirabegron because the meds were out of stock or not obtained from the pharmacy, with the DON confirming the missed doses and unrelieved pain were significant.
A resident with moderately impaired cognition and cerebral amyloid angiopathy had a weekly buprenorphine patch order inaccurately transcribed as Suboxone on the MAR. Staff also applied a new pain patch without removing the old one, leaving two active patches on the resident for several days. The DON stated the admission verification process was not followed and the incident was not investigated.
A resident with DM2 and multiple chronic conditions had an order for daily insulin glargine, but an RN documented that the dose was not given because the medication was unavailable. An LPN stated staff should reorder meds when five doses remain and, if out, notify the provider and pharmacy and use the emergency medication supply system; an RN and the DON confirmed backup insulin was available in a lockbox, and the DON noted there was no documentation explaining the omission.
Significant morphine dose error
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when an RN administered 5 mg of morphine sulfate instead of the prescribed 2 mg dose. The resident had severe cognitive impairment and diagnoses that included Alzheimer's disease, coronary artery disease, and dementia. The physician orders directed morphine sulfate concentrate oral solution 100 mg/5 mL to be given as 2 mg (0.1 mL) buccally every four hours for pain, with a separate PRN order for 5 mg (0.25 mL) buccally every hour as needed for breakthrough pain or shortness of breath. The EMAR showed the resident received the scheduled 2 mg dose at 4:00 p.m. and did not show a PRN 5 mg dose. During observation, RN-B withdrew 0.25 mL of morphine sulfate using the syringe provided with the medication and administered it buccally to the resident, then documented on the narcotic record book that 0.1 mL had been given. RN-B stated she gave 0.25 mL because the medication box label identified 0.25 mL, while RN-A stated the correct dose was 0.1 mL and acknowledged the error after RN-B confirmed the amount administered. The resident was assessed after the error and remained unchanged, with vital signs and condition stable. The DON stated the medication label had been followed instead of the EMAR, and the consultant pharmacist stated the resident could have experienced increased drowsiness from the error.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when it did not follow insulin pen preparation instructions for Resident #8. Resident #8 was admitted with multiple diagnoses including cerebral infarction (stroke), aphasia, and diabetes, and had a physician order for Humalog (Lispro) insulin pen-injector 100 units/ml to be injected subcutaneously at 5 units before meals for type 2 diabetes. During observation on 8/4/26, an LPN removed the Humalog insulin pen from the medication cart and dialed it to the ordered 5 units, but did not prime the pen with 2 units before administering the dose. The insulin was then given to Resident #8. When interviewed shortly afterward, the LPN stated she did not prime the insulin pen and was unaware of the need to do so before administering insulin. The DON stated insulin pens should be primed according to the manufacturer's instructions and had not been.
Significant medication error involving crushing a do-not-crush ER medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a Medication Aide crushed and administered medications that included Potassium Chloride ER, despite a physician order stating the medication was to be given by mouth twice daily and not crushed. The resident had diagnoses of chronic diastolic heart failure and dysphagia following a cerebral infarction, and the physician’s orders contained no instruction to crush medications. The facility policy stated medications should be administered as ordered and that medications with do-not-crush instructions, including slow release and enteric coated medications, should not be crushed. During observation, the Medication Aide confirmed they were going to crush all of the resident’s morning medications except Pantoprazole. The aide then placed Clopidogrel, Potassium Chloride ER, Sertraline, and Torsemide into a medication cup, crushed them, added pudding, and fed the mixture to the resident. The record review also identified Potassium Chloride as a high alert medication and cited guidance stating that enteric-coated or extended-release tablets or capsules should not be chewed or crushed.
Significant medication errors from delayed and missed ordered medications
Penalty
Summary
The facility failed to obtain physician-ordered medications in a timely manner, resulting in significant medication errors for two residents. One resident was admitted to the facility on 7/9/26 under hospice care with end-stage heart failure and had an order for Morphine Sulfate concentrate 10 mg sublingually every hour as needed for pain and/or air hunger. The resident did not receive Morphine on the day of admission, and the first documented dose was not given until 7/10/26 at 1:41 p.m., about 26 hours after admission. The MAR documented 26 potential missed PRN doses, and the resident’s family member and an LPN stated the medication was not available when needed and that the resident had signs of pain during that period. A second resident had orders for a Lidocaine external patch once daily for mild pain and Mirabegron ER 25 mg daily for urinary antispasmodic use. The MAR and nursing notes documented that the Lidocaine patch was not administered for multiple days because it was out of stock, with missed applications documented on 7/26, 7/27, 7/29, and 7/30, and 7/28 signed in error as given. The resident stated the missed patches prevented comfortable sleep. The same resident also missed Mirabegron doses on multiple days because the medication was on order from the pharmacy and not available, with documentation showing missed administration on 7/14, 7/15, 7/16, 7/17, 7/19, 7/20, and 7/21, and one date documented as given in error. The DON confirmed the Lidocaine order did not include a dose and acknowledged the resident missed several doses because the facility ran out of the patches. The DON also confirmed the Mirabegron was not supplied as expected and that the convenience box did not contain that medication. The resident and family member stated the missed medications affected pain control, sleep, and urinary urgency, and the DON stated the quantity of missed doses and unrelieved pain equated to significant medication errors.
Medication Order Transcription Error and Duplicate Pain Patch Application
Penalty
Summary
The facility failed to ensure a resident remained free from significant medication errors when admission medication orders were not accurately transcribed to the MAR. The resident was admitted with diagnoses including cerebral amyloid angiopathy, and the comprehensive assessment showed moderately impaired cognition and a need for assistance from one staff member with ADLs. The hospital discharge orders included a weekly buprenorphine transdermal patch, but the July 2026 MAR listed the medication as a weekly Suboxone transdermal patch instead. Staff later stated the wrong medication name was entered because Suboxone was believed to be the same medication as buprenorphine, and the admission body check was not completed to determine whether a transdermal patch was already present. The resident representative reported that facility staff applied a new pain patch without removing the old one, leaving two active patches on the resident for three days. Staff later confirmed one patch was on the right shoulder and another on the left shoulder, and the older patch was then removed. The DON stated the facility’s medication error process included staff interviews, physician notification, alert charting, and monitoring for high-alert medications, but also stated the incident was not investigated and no medication error report was completed. The DON further stated the admission process required a three-step verification of orders, and that process was not followed for this resident.
Missed Insulin Dose Due to Medication Unavailability
Penalty
Summary
A resident with type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and obesity had a physician order for Insulin Glargine Solostar 300 units/mL, 50 units subcutaneously once daily. On 3/20/26 at 11:19 AM, an RN documented that the insulin was not administered because the medication was unavailable. During interviews on 7/30/26, an LPN stated that medications should be reordered through the eMAR when five doses remain and that if a medication is completely out, staff must immediately notify the provider and pharmacy and use the emergency medication supply system. An RN confirmed that backup insulin was available in a lockbox in the third-floor refrigerator and that staff should not run out of insulin. The DON also confirmed the backup insulin location and the pharmacy restocking alert system, and stated there was no documentation in the progress notes or TAR explaining the omission; because she was not employed at the facility at the time, the exact reason for the unavailable medication and omitted dose remained unknown.
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