Medication Errors Affecting Residents
Summary
The facility staff failed to ensure that three residents were free from significant medication errors. For one resident, the staff held the blood pressure medication amlodipine without a physician's order, despite the resident having a diagnosis of hypertension. The medication was not administered on three occasions due to low blood pressure readings, but there were no parameters in the order to justify holding the medication. This issue was discussed with the facility's administration, but no further information was provided before the survey exit. Another resident did not receive their prescribed medications, Xarelto and Lasix, as per the physician's orders. The medications were marked as not administered due to unavailability, even though the facility's emergency medication supply included these medications. This resident had a history of pulmonary embolism and was on anticoagulant and diuretic therapy. The failure to administer these medications was also discussed with the facility's administration, but no additional information was provided before the survey exit. The third resident continued to receive morphine after a verbal order to discontinue the medication was given. The order was not implemented, and the resident received multiple doses of morphine after the discontinue order was issued. The facility's administration was unaware of when the discontinue order was provided to the facility, although it was uploaded into the electronic record. This issue was discussed with the facility's administration, but no further information was provided before the survey exit.
Penalty
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Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
Three residents with complex medical histories did not receive multiple prescribed medications as ordered due to unavailability, lack of timely pharmacy delivery, and inconsistent staff response. Despite facility policy requiring physician notification and consideration of alternative therapies, there was no documentation that these steps were taken. Nursing staff interviews revealed uncertainty about proper procedures, and leadership acknowledged process gaps that contributed to the medication errors.
A resident admitted with a candida UTI did not receive a prescribed antifungal medication for three days because staff failed to transcribe the physician's order at admission. The medication was only started after the delay was identified during a chart check, despite facility policy requiring prompt recording of all admission orders by nursing staff.
A resident with multiple complex medical conditions was given double the prescribed dose of quetiapine on two occasions due to a transcription error, and staff failed to notify the physician or consult the pharmacy when severe drug interaction alerts appeared in the system. Interviews confirmed that staff did not follow protocols for provider notification, and the issue was identified during the survey.
A resident with multiple medical conditions and moderate cognitive impairment received Midodrine for low blood pressure despite physician orders to hold the medication when systolic blood pressure exceeded specified limits. The MAR showed that staff administered the medication on several occasions when the resident's blood pressure was above the ordered parameters, contrary to the physician's instructions.
A resident experienced a significant medication error due to a failure in the medication administration process.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
Facility staff failed to ensure that three residents were free from significant medication errors, as evidenced by multiple instances where prescribed medications were not administered according to physician orders. For one resident with a history of stroke, heart failure, and pneumonia, medications including Levoquin, Umeclidinium-Vilanterol, and dexamethasone were documented as unavailable on several occasions. Despite the presence of alternative medications in the Omnicell and a facility policy requiring physician notification and alternative therapy consideration, there was no documentation that the physician was notified or that alternative medications were considered or administered. Another resident with Parkinson's disease, diabetes, and a history of CVA did not receive Eliquis, Carbidopa-Levodopa, and sertraline as ordered. The clinical record showed repeated notations of medications being on order or awaiting pharmacy delivery, even though some of these medications were available in the Omnicell. There was no evidence that the physician was notified about the unavailability of these medications, nor was there documentation of any action taken to address the missed doses as required by facility policy. A third resident with multiple chronic conditions, including COPD, diabetes, and vascular dementia, also experienced missed doses of several medications such as Dapagliflozin, Incruse Ellipta, Buspar, and Ipratropium. Medication administration records and nurses' notes repeatedly indicated that medications were not available, on order, or delayed due to insurance issues, with no evidence that the medical provider was notified in a timely manner. Interviews with nursing staff revealed inconsistent understanding of the procedures to follow when medications were unavailable, and the Interim Director of Nursing acknowledged that some residents were not entered into the pharmacy's automatic refill program, contributing to the medication errors.
Delayed Initiation of Antifungal Medication Due to Failure to Transcribe Admission Order
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors by not transcribing a physician's order for an antifungal medication upon admission. The resident, who had been diagnosed with a candida urinary tract infection during a recent hospitalization, was discharged with an order to begin fluconazole 200 mg daily for thirteen days. Upon review, it was found that the order for fluconazole was not entered into the facility's system at the time of admission, resulting in a three-day delay before the medication was started. The medication was eventually initiated, but only after the delay was identified during a chart check by the unit manager. Interviews with nursing staff confirmed that there was no reason for such a delay, as medications are typically available in the facility's automated dispensing system or can be delivered by the pharmacy multiple times a day. The facility's policy requires that all admission physician orders, including medications, be recorded by a licensed nurse upon admission, but this process was not followed in this instance. The Director of Nursing confirmed that the medication should have been started as ordered and acknowledged the lapse in following the established procedure.
Failure to Administer Correct Medication Dose and Notify Providers of Drug Interaction Alerts
Penalty
Summary
Facility staff failed to order and administer the correct dose of quetiapine fumarate for a resident, resulting in the resident receiving double the prescribed amount on two occasions. The resident, who had multiple complex medical conditions including COPD, asthma, chronic respiratory failure, major depressive disorder, and moderate cognitive impairment, was admitted with specific medication orders from the hospital. However, discrepancies occurred during the transcription of these orders, leading to the administration of 25 mg of quetiapine instead of the intended 12.5 mg. The error was not identified until after the incorrect doses had been given. Additionally, when entering the resident's medications into the pharmacy system, multiple drug-to-drug interaction alerts were triggered, some of which were classified as severe. These included potential additive QT interval prolongation and increased risk of serotonin syndrome due to the combination of several psychotropic and other medications. Despite these alerts, there was no documentation that the physician was notified or that the pharmacy was consulted regarding the warnings. Interviews with facility staff, including an LPN and the DON, confirmed that the expectation was for nurses to notify physicians and consult with the pharmacy when such alerts occur. However, the staff did not follow these protocols, and the prescribing providers were not made aware of the medication errors or the significant drug interaction warnings. The deficiency was brought to the attention of the facility administration during the survey process.
Failure to Follow Medication Hold Parameters for Blood Pressure Medication
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors by not adhering to physician orders regarding the administration of Midodrine, a medication used to treat low blood pressure. The resident, who had multiple diagnoses including interstitial pulmonary disease, generalized anxiety disorder, major depressive disorder, unspecified dementia, dysphagia, Barrett's esophagus, and generalized weakness, was assessed as having moderate cognitive impairment. Physician orders specified that Midodrine should be held if the resident's systolic blood pressure exceeded certain thresholds, initially greater than 130 mmHg and later changed to greater than 120 mmHg. A review of the Medication Administration Record (MAR) for September and October showed that staff administered Midodrine on several occasions when the resident's systolic blood pressure was above the ordered parameters. Specifically, the medication was given when the resident's systolic blood pressure was recorded as 139, 132, 145, and 131 mmHg, all above the hold parameters set by the physician. Interviews with nursing staff and the Director of Nursing confirmed the expectation that physician orders should be followed exactly as prescribed, but the records demonstrated that this did not occur.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
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