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
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Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors observed two medication administration errors that caused the facility’s medication error rate to exceed 5%. In one case, an LPN administered insulin using a pen device to a resident with diabetes without priming the pen as required by the manufacturer’s instructions. In another case, an LPN measured a resident’s ordered 17 g dose of MiraLAX by filling the product cap only partway instead of to the top rim as specified on the container, then administered the inaccurately measured dose. These actions resulted in a calculated medication error rate of 7.14% during the survey.
Surveyors observed an LPN administering insulin to a resident with type 2 DM and daily insulin orders without priming either the lispro or Lantus insulin pens before dialing and giving the doses, contrary to manufacturer instructions requiring priming before each injection. The resident’s blood sugar was elevated, and the LPN confirmed the pens were not primed. This contributed to 2 errors in 25 opportunities, resulting in a medication error rate above the 5% threshold.
Surveyors found that the facility exceeded the acceptable medication error rate when, during a morning med pass, an RN was unable to administer an ordered dose of Synthroid to a resident with diabetes, hypothyroidism, and hypertension because it was not available in the med cart or emergency box, and also failed to remove a scheduled dose of glipizide from the medication card until prompted by the surveyor. These two omission errors, identified during observation and confirmed in staff interviews and record review, resulted in a 7% medication error rate for 28 observed medication opportunities.
Surveyors found the facility exceeded the acceptable medication error rate when an LPN administered multiple ophthalmic medications to a resident with complex medical conditions and moderate cognitive impairment. The LPN instilled Atropine and Prednisolone, which were ordered for only one eye, into both eyes, and also gave Brimonidine and Brinzolamide in both eyes without clarifying an incomplete order for Brinzolamide. The LPN did not observe the required time intervals between different eye drops as specified by manufacturer instructions and facility policy, contributing to four medication errors during a single medication pass.
Surveyors found that the facility’s medication error rate exceeded 5% when two residents with type 2 DM did not receive insulin as ordered. For one resident, an LPN administered eye drops and oral medications but held the ordered morning Lantus dose without resident refusal, provider notification, or any order parameters to hold the insulin, despite facility policy requiring prescriber contact if a dose is believed inappropriate. For another resident, an RN administered Lantus using a pen device without performing the required priming/safety test steps outlined in the manufacturer’s instructions, instead only checking for air bubbles before injection. These two insulin-related errors, out of 34 observed opportunities, resulted in a 5.8% medication error rate.
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Medication Administration Errors Result in Exceeding 5% Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors in 28 medication administration opportunities, resulting in a 7.14% error rate. For one resident with diabetes mellitus who was cognitively intact and received insulin injections daily, the physician’s order directed administration of insulin aspart 23 units SQ with meals. During observation of a medication pass, an LPN removed the insulin aspart pen from the cart, dialed the pen directly to 23 units, attached the needle, and administered the dose without priming the pen. The LPN confirmed she did not prime the pen and acknowledged that her usual practice would be to prime the pen, then dial the required dose, then place the needle on the pen. Manufacturer instructions for the KwikPen specified that the pen must be primed before each injection by selecting 2 units, holding the pen needle-up, tapping to move air bubbles, and pushing the dose knob until insulin is seen at the needle tip before dialing the prescribed dose. In a separate incident, another resident with Crohn’s disease, diverticulosis, constipation, severe cognitive impairment, and frequent bowel incontinence had a physician’s order for MiraLAX powder 17 g PO once daily. During an observed medication administration, an LPN measured the MiraLAX powder by filling the product cap only to just under the very bottom line inside the lid, then poured this amount into water for administration. When asked to read the product instructions, the LPN reviewed the MiraLAX container, which stated that the bottle cap is a measuring cup designed to contain 17 g when filled to the top rim. The LPN confirmed that the MiraLAX had not been measured according to the manufacturer’s instructions. These two observed medication administration errors formed the basis of the cited deficiency under the referenced complaint investigation.
Failure to Prime Insulin Pens Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 2 errors in 25 medication administration opportunities, resulting in an 8% error rate. The affected resident had type 2 diabetes mellitus and was moderately cognitively impaired, with physician orders for multiple insulin regimens, including insulin lispro per sliding scale, a fixed daily dose of insulin lispro with instructions to adjust based on meal intake, and a daily morning dose of Lantus. The resident’s care plan identified risk for complications and blood glucose fluctuations related to diabetes and insulin use, with an intervention to administer insulin as ordered. During observation, an LPN checked the resident’s blood sugar, which was 332, and confirmed the resident had eaten 100% of breakfast. The LPN then prepared the resident’s insulin by dialing 34 units on the lispro pen and 50 units on the Lantus pen without priming either pen before setting the doses. The LPN proceeded to administer both insulin injections without performing the priming step. In a subsequent interview, the LPN confirmed that she did not prime the insulin pens prior to dialing in and administering the doses. Manufacturer instructions for the KwikPen, reviewed by surveyors, specified that the pen must be primed before each injection to remove air and ensure proper function, indicating that the observed practice did not follow the manufacturer’s directions for use.
Medication Omission Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 28 medication administration opportunities and two medication omission errors, resulting in a 7% error rate. The deficiency involved one resident who had been admitted with diagnoses including type 2 diabetes mellitus, hypothyroidism, and hypertension. Physician orders for this resident included Synthroid 50 mcg once daily and glipizide 10 mg every morning. During a morning medication pass, an RN was observed attempting to administer the resident’s medications and was unable to locate the ordered Synthroid in the medication cart or emergency box, resulting in a missed dose. During the same observation, the RN pulled the resident’s glipizide card from the medication drawer but did not remove the scheduled dose before returning the card to the drawer. Before the RN administered the morning medications, the surveyor intervened and questioned whether the glipizide dose had been removed, at which point the RN confirmed it had not and then retrieved the medication for administration. In subsequent interviews, the RN confirmed that Synthroid was not available for administration and that glipizide was only given after the surveyor’s intervention. The DON acknowledged that these two omission errors for Synthroid and glipizide, out of 28 opportunities, resulted in a 7% medication error rate for the observed medication pass.
Medication Error Rate Exceeded Due to Improper Ophthalmic Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 4 errors in 34 opportunities, resulting in an 11.76% error rate. The deficiency involved one resident who was admitted with diagnoses including respiratory failure, malnutrition, embolism of the right upper extremity and bilateral lower extremities, anemia, and hypotension, and who had moderate cognitive impairment and required substantial assistance with activities of daily living. The resident’s March physician orders included multiple ophthalmic medications: Brinzolamide 1% eye drops ordered as one drop twice a day without specifying which eye(s); Brimonidine 0.2% eye drops ordered as one drop in each eye twice a day; Atropine 1% eye drops ordered as one drop in the right eye; and Prednisolone Acetate 1% eye drops ordered for the right eye once daily. During observed medication administration, an LPN prepared the resident’s morning eye medications and then administered Atropine, Prednisolone, Brimonidine, and Brinzolamide in both eyes in rapid succession, without waiting the required interval between different eye drops. The LPN confirmed she did not wait five minutes between administering the eye drops, despite facility policy and manufacturer instructions requiring a waiting period between multiple ophthalmic products. She also acknowledged administering Atropine, Prednisolone, and Brinzolamide in both eyes because the resident requested drops in both eyes, even though the orders for Atropine and Prednisolone specified the right eye only and the Brinzolamide order lacked clarification regarding which eye(s) to treat. The Brinzolamide order was not clarified with the physician, contrary to facility policy requiring clarification of incomplete or questionable medication orders. Manufacturer instructions for all four medications specified waiting at least five minutes between drops (and ten minutes for Brinzolamide when used with another eye medication), which was not followed.
Medication Error Rate Exceeded 5% During Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 34 opportunities, resulting in a 5.8% error rate. For one resident with type 2 diabetes mellitus and multiple comorbidities, the care plan included administration of insulin as ordered. The physician’s order specified Lantus 18 units subcutaneously in the morning. During a morning medication pass, an LPN administered the resident’s eye drops and oral medications but held the ordered Lantus dose, despite the resident not refusing the injection and there being no parameters in the order to hold it. The LPN later confirmed she did not contact the provider and that the resident’s blood sugar that morning was 97, and facility policy required contacting the prescriber if a dosage was believed to be inappropriate or excessive. For a second resident with type 2 diabetes mellitus and other diagnoses including dementia, depression, and chronic kidney disease, the care plan identified risk for hyper/hypoglycemia with an intervention to administer medications as ordered. The physician’s order specified Lantus SoloStar 10 units subcutaneously in the morning. During observation of a medication pass, an RN prepared the Lantus pen by attaching a needle and dialing the dose to 10 units but administered the injection without priming the pen. In interview, the RN stated she checked the pen for air bubbles but did not know any other way of priming it. The manufacturer’s instructions for the Lantus SoloStar pen require performing a safety test before each injection, including selecting 2 units, removing caps, holding the pen needle-up, tapping to move air bubbles, and pressing the injection button to ensure insulin comes out and the dose window returns to 0. These observed deviations from ordered insulin administration and manufacturer instructions contributed to the calculated medication error rate above 5%.
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