Medication Error Rate Exceeds Acceptable Threshold
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 26.92% error rate during a survey. This deficiency affected two residents, who did not receive their prescribed medications as ordered by their physicians. Resident 5 missed doses of metoprolol and bumetanide, while Resident 31 missed doses of Eliquis, brimonidine, finasteride, folic acid, and tamsulosin. These omissions were observed during a medication administration task. The errors were attributed to the unavailability of medications in the facility's medication carts and emergency kits. Licensed nurses, including LVN 1, failed to reorder medications from the pharmacy within the required three to five-day timeframe before the last available dose. This led to the medications not being available for administration at the scheduled times, as confirmed by interviews with the DON and LVN 1. The facility's policies and procedures for medication administration and reordering were not consistently followed. The DON acknowledged the lack of a consistent system for timely reordering and follow-up of medications, which contributed to the medication errors. The failure to administer critical medications as prescribed posed a risk to the residents' health and safety.
Removal Plan
- Under the direction and leadership of the DON, all necessary medications for Residents 5 and 31 were reordered.
- Licensed Vocational Nurse 1 (LVN 1) completed Situation, Background, Assessment, Recommendation (SBAR) for Resident 5 for the potential change of condition related to the unavailability of medications and notified Physician 1 (P 1).
- LVN 1 completed SBAR tool for Resident 31 for the potential change of condition related to the unavailability of medications and notified Medical Director 1 (MD 1).
- P 1 ordered laboratory (lab) tests for Resident 5 and MD 1 ordered stat (emergent) lab tests for Resident 31.
- Resident 5 and Family Representative 1 (FR 1) were made aware by The Interdisciplinary Team (IDT) and MD 1 of the medication omissions, lab tests ordered by P 1, and updated plan of care related to the medication omissions. Resident 31 was made aware by the IDT and MD 1 of the medication omissions, lab tests ordered by MD 1, and updated plan of care related to the medication omissions.
- The IDT conducted a meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered lab tests, and updated plan of care related to the medication omissions for Resident 5. The IDT conducted meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered stat lab tests, and updated plan of care related to the medication omissions for Resident 31.
- The Consulting Pharmacist (CP) and Consulting Pharmacy Registered Nurse 1 (CPRN 1) conducted an audit of Medication Cart 1 to reconcile medications on hand against the physician orders for Residents 5 and 31, and all medications were on hand.
- MD 1 conducted physical assessments and provided progress notes for Residents 5 and 31. No untoward findings or side effects related to medication omission have been noted for either Resident 5 or 31.
- The DON, the Director of Staff Development (DSD), and LVN 2 conducted an audit of Medication Carts 1 and 2 to reconcile medications on hand and medication administration record against the physician orders and identified 12 residents with total of 17 medications with less than 5 days' supply on hand and re-ordered the medications.
- The CP and CPRN 1 conducted audits of Medication Carts 1 and 2 to reconcile medications on hand against the physician orders for all residents and identified nine remaining residents each with one medication with less than five-day supply on hand that was already re-ordered.
- A Root Cause Analysis (RCA) was initiated by the ADMIN and the DON to determine causative factors for the systemic breakdown.
- The DON conducted in-service for the licensed nursing staff regarding the following: Daily review of resident medication supply for availability, ensuring residents receive mediations as prescribed by the physician and administered at the scheduled times, ensuring all licensed nurses are following facility policy and procedures on Ordering and Receiving medications from the Dispensing Pharmacy, indicating that medications are re-ordered five days in advance, following through daily with the dispensing pharmacy for timely delivery of all ordered medications, how to utilize the Medication Refill Audit Tool.
- The DON or designee will track the following during the Daily Nursing Huddles: Timely (5 days) Ordering of Medications, Timely Delivery of Medication, Timely Administration of Medication.
- The DON or designee will present findings at the Daily Stand-Up Meeting for immediate intervention as warranted by the ADMIN and/or IDT. Trends will be discussed with MD 1, the IDT, and any relevant parties such as vendor pharmacy to support process improvement until 100% compliance is achieved.
- The CP and CPRN 1 will conduct critical medication pass audits with randomly selected licensed nurse monthly. The DON or designee will conduct medication pass audits with selected licensed nurse weekly. Trends will be discussed with MD 1, the IDT, and/or any relevant parties such as vendor pharmacy weekly or as often as necessary to support process improvement until 100% compliance is achieved.
- The ADMIN will monitor the outcomes of the systemic change. Any trends noted shall be discussed at Quality Assurance Performance Improvement (QAPI) meetings with modifications to the process as warranted.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LPN contributed to a medication error rate of 10.71% after 3 errors were found in 28 observed medication opportunities. The LPN administered eye drops and ear drops to one resident without preventing the resident from wiping the medication away, and left another resident unsupervised during a nebulizer treatment without monitoring the response or cleaning the equipment afterward. Record review showed the resident receiving the nebulizer had no documentation supporting self-administration, and the facility's procedures required assessment and direct administration for these treatments.
Medication administration errors exceeded the allowed rate, with surveyors identifying multiple dose discrepancies and an enteral medication error during observed med passes. An MA gave a resident the wrong ferrous sulfate dose, another MA gave a resident several medications at incorrect strengths, and an LVN used another resident’s MiraLAX and did not complete the ordered G-tube water flushes before administration.
Medication error rate exceeded the allowed threshold. Surveyors calculated a 6.25% error rate based on 32 medication opportunities with 2 errors. In one case, an LPN gave a resident the wrong magnesium/calcium tablet strength compared with the active order for hypomagnesemia. In another, an LPN administered vitamin D3 400 units even though the resident’s order called for cholecalciferol 4000 units for vitamin D deficiency, and staff noted the pharmacy label still showed 400 units.
The facility’s medication error rate was 6.9%, with 2 errors found in 4 observed med passes. One nurse gave an insulin dose without priming the pen first, and another did not ensure a resident rinsed and spit after using a steroid-containing inhaler. The residents involved had DM and COPD, respectively, and both were moderately cognitively impaired.
Medication Error Rate Exceeded Standard During G-Tube Medication Administration. Surveyors found a 27.59% medication error rate during observation of medication administration. An LPN crushed multiple meds together, mixed them with water, and administered them through a resident’s g-tube without giving each medication separately. The resident had encephalopathy, dysphagia, malnutrition, severe cognitive impairment, and required tube feeding for nutrition. The resident’s orders did not include permission to combine the tablets, and the DON and ADON stated meds for tube administration should not be cocktailed.
Medication administration errors exceeded the allowed rate when seven errors were found in 31 opportunities. A nurse gave several scheduled meds to one resident more than 2 hours late, and another nurse crushed and gave three meds together through a G-tube to another resident instead of administering each med separately with flushes between doses, contrary to the DON’s expectations, the consultant pharmacist’s guidance, and facility policy.
Medication Error Rate Exceeded Threshold During Eye, Ear, and Nebulizer Administration
Penalty
Summary
A medication error rate of 10.71 percent was identified after 28 medication opportunities were observed and 3 errors were found, exceeding the 5 percent threshold. During one observation, an LPN administered prescribed eye drops to a resident with blepharitis and instilled 2 drops in each eye, but did not offer tissue or instruct the resident not to rub his eyes afterward; the resident immediately rubbed both eyes with his t-shirt and removed the drops. The same LPN then administered ear drops by placing the dropper tip inside the ear canal and instilling drops into both ears, after which the resident again wiped the drops away with his t-shirt. During another observation, the LPN prepared and started a nebulizer treatment for a resident who had an order for ipratropium-albuterol inhalation solution three times daily. The LPN handed the mask to the resident, instructed him to place it on himself, washed her hands, and left the room, leaving the resident unsupervised during the treatment and without monitoring the response or cleaning and disassembling the nebulizer equipment afterward. The LPN confirmed that the nebulizer treatment should not have been left unattended and that she did not perform an assessment before or after medication administration. Record review showed the resident had no documentation indicating self-administration of medications, and the facility's procedures required assessment, direct administration, and post-treatment evaluation for nebulizer use, as well as specific techniques for eye and ear drop administration.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. Surveyors identified a 26.67% medication error rate, based on 8 errors out of 31 opportunities, involving 3 residents and 3 staff members observed during medication administration. The errors included incorrect doses of ferrous sulfate for one resident and multiple medication dose discrepancies for another resident, as well as an error involving a third resident’s enteral medication administration. One resident with a history of cerebral infarction, muscle wasting, constipation, hypertension, and mixed hyperlipidemia had a physician order for ferrous sulfate 326 mg by mouth daily. During observation, MA I administered ferrous sulfate 325 mg instead. The resident had severely impaired cognition, with a BIMS score of 3 out of 15. During interview, MA I stated she did not notice the milligram difference and acknowledged she was responsible for ensuring the dosage was correct before administration. Another resident with osteomyelitis, muscle wasting, and anemia had orders for ferrous gluconate 324 mg, magnesium oxide 250 mg, vitamin C 1000 mg, folic acid 1000 mcg, and methocarbamol 1000 mg. During observation, MA F administered ferrous gluconate 325 mg, magnesium oxide 240 mg, vitamin C 500 mg, folic acid 400 mcg, and methocarbamol 500 mg. A third resident with cerebral infarction, dysphasia, and abdominal pain had an order for MiraLAX via G-tube and water flushes before and after medication administration. During observation, LVN N used another resident’s MiraLAX bottle, mixed it with water, and administered it without the ordered 50 cc water flush before medication administration.
Medication error rate exceeded the allowed threshold
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent; surveyors calculated a 6.25 percent error rate based on 32 medication opportunities with 2 medication errors. During observation of a medication pass for one resident, an LPN administered a Slow Magnesium/Calcium oral tablet 70-117 mg, while the active physician order called for Slow Magnesium/Calcium Delayed Release 64-106 mg, 1 tablet by mouth every morning and at bedtime for hypomagnesemia. During another medication pass observation, an LPN administered vitamin D3 400 units to a second resident. The resident’s active physician order, dated January 23, 2026, directed staff to administer cholecalciferol oral tablet 100 micrograms (4000 units), 1 tablet by mouth in the morning for vitamin D deficiency. An LPN later stated that the pharmacy supply continued to label the resident’s vitamin D3 supplement as 400 units, and confirmed that the physician order required 4000 units in the morning.
Medication Error Rate Exceeded Threshold; Insulin Pen Not Primed and Inhaler Rinse Not Completed
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent, with a measured medication error rate of 6.9 percent. During observation, record review, and staff interviews, surveyors identified 2 medication administration errors out of 4 observed administrations: one involving an insulin pen that was not primed before the ordered dose was given, and one involving an inhaled steroid medication where the resident was not instructed or assisted to rinse her mouth with water without swallowing after use. Resident #38 had diabetes mellitus and was moderately cognitively impaired. A physician ordered insulin degludec 58 units subcutaneously once daily. During observation, a nurse obtained the insulin pen, attached the needle, dialed the pen to 58 units, and administered the injection without first priming the pen. The nurse later stated she normally primes insulin pens but forgot to do so while being observed. Staff Development, the DON, the NP, and the Administrator all confirmed that the pen should have been primed according to the manufacturer’s instructions before the dose was administered. Resident #50 had COPD and was moderately cognitively impaired. A physician ordered fluticasone furoate, umeclidinium, and vilanterol aerosol powder, 1 puff daily, with instructions to rinse the mouth after use. During observation, the resident used the inhaler, but the nurse did not provide water or instruct the resident to rinse and spit afterward; instead, the resident was given laxative solution mixed with water and drank it. The nurse acknowledged she did not offer or encourage the rinse and stated the resident had refused in the past, but those refusals had not been documented or reported. The DON, NP, and Administrator confirmed that the mouth rinse should have been offered and that prior refusals should have been documented and communicated.
Medication Error Rate Exceeded Standard During G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure the medication error rate was not 5% or greater. Surveyors found a medication error rate of 27.59%, based on 8 errors out of 29 opportunities, involving 1 of 5 residents and 1 of 3 staff observed during medication administration. The deficiency centered on Resident #6, a male with diagnoses including encephalopathy, dysphagia, and malnutrition, whose cognitive skills were severely impaired and who required a feeding tube for nutrition. His care plan reflected the need for tube feeding for all nutrition and checking tube placement per facility protocol. During observation, LVN F prepared multiple medications together in one medication cup, including Vitamin D3, acetaminophen, ascorbic acid, zinc sulfate, thiamine, Eliquis, tizanidine, and atorvastatin, then crushed the tablets together and mixed them with water. LVN F entered the resident’s room and administered the medications through the g-tube without giving the tablets separately. The nurse also administered multivitamin and Prostat through the tube during the same medication pass. The resident’s order summary reflected no physician order to combine medication tablets or cocktail medications. In interview, LVN F stated he typically crushed medications together if they were not enteric coated and acknowledged that giving the medications together could put the resident at risk of medication interaction and cause an adverse reaction. The ADON and DON both stated that medications for g-tube administration should be crushed and administered separately and not cocktailed.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5% when seven medication errors were identified out of 31 opportunities, resulting in a medication error rate of 22.58% for a census of 91. During a concurrent medication administration observation and interview, a nurse prepared and administered four medications for one resident after the scheduled 8:00 a.m. time, with the medications given between 10:04 a.m. and 10:14 a.m. The resident’s orders included hydralazine hydrochloride 50 mg via G-tube every 8 hours, metoprolol tartrate 25 mg via G-tube twice daily, levetiracetam 100 mg/mL 10 mL via G-tube twice daily, and Humulin R 8 units subcutaneously three times daily. The DON stated medications should be given within one hour before and one hour after the scheduled time, and the facility policy stated medications are to be administered within one hour of the prescribed time. During another medication administration observation, a nurse crushed and combined three medications together and administered them via G-tube to another resident: carvedilol 12.5 mg, empagliflozin 10 mg, and sacubitril-valsartan 49-51 mg. The consultant pharmacist stated these medications should not be crushed together because there was no literature supporting that crushing and administering them together would avoid physical or chemical incompatibilities, and nurses were expected to crush medications individually and administer each medication with flushes in between. The facility’s policy for administering medications through an enteral tube stated that each medication should be administered separately and flushed between medications.
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