Medication Error Leads to Resident's Acute Psychotic Event and Injury
Summary
The facility failed to administer six doses of a required antipsychotic medication, Clozapine, to a resident diagnosed with paranoid schizophrenia. This resident, who was stable and adhering to his medication regimen, experienced an acute psychotic event after missing these doses, resulting in a fall that caused a broken shoulder and hip, requiring surgical repair. The incident occurred because the necessary laboratory tests, required by the pharmacy to dispense the medication, were not completed and sent in a timely manner. The resident had a physician's order for Clozapine to be administered twice daily, but the medication was put on hold due to missing laboratory results needed for pharmacy approval. Despite the order for a STAT lab test, the results were not faxed to the pharmacy promptly, leading to a delay in medication delivery. The resident's behavior deteriorated significantly during this period, culminating in a fall while attempting to confront staff, which resulted in severe injuries. Interviews with staff revealed a lack of communication and follow-through regarding the medication and laboratory requirements. The medication aide and nurses involved were aware of the importance of the medication and the need for lab work but failed to ensure the necessary steps were taken to prevent the medication error. The facility's failure to manage the medication administration process effectively led to the resident's acute psychotic episode and subsequent injuries.
Removal Plan
- Resident #11's medication of Clozapine was administered to the resident as ordered by the provider.
- An audit of all current residents was completed by the Director of Nursing to determine if any other residents required lab work previous to medication distribution from pharmacy.
- Licensed nurses were educated on the new process that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider is notified to review. When applicable, a separate order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. The providers were educated of the new process by the Director of Nursing. When the order appears on the Medication Administration record, the licensed nurse will ensure the lab results are faxed to the pharmacy.
- Education was provided by the Director of Nursing to licensed staff and licensed agency staff that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider when applicable will order for lab results to be faxed to the pharmacy. The order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. When the order appears on the medication administration record, the licensed nurse will ensure the lab results are faxed to the pharmacy.
- The Quality Assurance team met and a decision was made that the Director of Nursing or Designee will audit that includes the following: the provider entered a physician order for lab work; the order was placed on the Medication Administration Record; a lab form was completed and placed in the lab book for the lab to be drawn; an order was placed to fax the results to pharmacy for medication distribution when applicable; the results were received and faxed to pharmacy when applicable; and the medication is administered as ordered by the provider to prevent a significant medication error; and when the order appears on the Medication administration record, the licensed nurse will ensure the lab results are faxed to the pharmacy. All ordered lab work will be reviewed from the previous day to ensure results have been reviewed by the provider and as applicable faxed to the pharmacy timely to prevent a significant medication error with ordered lab work through the weekend reviewed for two weeks and then weekly for ten weeks. Results of these audits will be presented by the Director of Nursing or Designee to the facility Quality Assurance and Performance Improvement (QAPI) Committee for review and, if warranted, further action.
Penalty
Resources
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Staff failed to administer multiple ordered medications, including antihypertensives, carbidopa-levodopa, and carvedilol, to three residents despite the drugs being available in the facility. One resident with severe cognitive impairment and a history of markedly elevated BP missed several doses of multiple antihypertensive agents shortly after admission, while BP readings remained elevated. Another resident with Parkinson’s disease and severe cognitive impairment did not receive several scheduled doses of carbidopa-levodopa, with no documentation of refusal. A third cognitively intact resident with acute systolic heart failure and hypertension did not receive an evening dose of carvedilol even though vital signs were within ordered parameters and the medication was on hand. The DON confirmed that these medications were not administered per physician orders, contrary to facility policies requiring administration as ordered and use of on-hand stock when needed.
A resident with type 2 DM and daily insulin orders, including sliding-scale lispro and scheduled Lantus, received insulin injections from an LPN who did not prime either insulin pen before administration. After confirming the resident’s elevated blood glucose and full meal intake, the LPN dialed specific doses on both lispro and Lantus pens and administered them without priming. In a later interview, the LPN acknowledged not priming the pens, despite manufacturer instructions requiring priming before each injection to remove air and ensure proper pen function.
A resident with small B-cell lymphoma and intact cognition had physician orders for nightly Ibrutinib capsules, including a specified hold period. Review of MARs showed that several doses were not administered on multiple days outside the ordered hold period, and there was no documentation in the record explaining the missed doses. The DON later reported that the pharmacy did not have the medication and believed the oncologist had stopped it, but this was not supported by any written orders or documentation, resulting in a significant medication error.
The facility failed to prevent significant medication errors for four residents. One resident returned from an outside visit with new orders for an antibiotic that was never documented as administered. Another resident with an indwelling catheter had a positive urine culture for pseudomonas and a physician order for Bactrim DS, but the MAR showed no doses given. A third resident with breast cancer had an oncology prescription for Verzenio that was not acted upon for several weeks despite the resident reporting she should be on a new cancer medication and staff contacting the oncology office without documented follow-up. A fourth resident with DM received Humalog insulin doses on several occasions when blood glucose values were below the ordered parameters, as confirmed by an RN.
A resident with severe cognitive impairment and multiple medical conditions, including infection and type II DM, had physician orders for Seroquel via J-tube three times daily and ciprofloxacin via J-tube every 12 hours. Audit review showed that the 9:00 A.M. doses of both medications were repeatedly administered several hours late over multiple days, outside the facility’s stated one-hour-before/after administration window, as confirmed by the DON. Resident Council minutes also reflected complaints about late medications, and facility policy required immediate documentation after medication administration.
Surveyors found that the facility failed to prevent significant medication errors, including administration of morphine and lorazepam without active orders to a hospice resident with severe psychiatric and neurological conditions, as documented in narcotic logs, hospice notes, and electronic messages. Other residents with glaucoma, heart failure, chronic pain, epilepsy, hemiplegia, and vascular dementia missed multiple scheduled 9 p.m. doses of ophthalmic agents, an anticoagulant (Eliquis), and an antiepileptic (topiramate), as shown on MARs and confirmed by a regional clinical director. These actions and omissions occurred despite a facility policy requiring verification of the right resident, medication, dose, time, and route before administration.
Failure to Administer Available Ordered Medications as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically related to not administering ordered medications despite their availability. One resident with type 2 diabetes, chronic kidney disease, hypertension, and hypokalemia was admitted with a history of chronically elevated systolic blood pressure up to the 190s and had multiple antihypertensive medications ordered from the hospital, including lisinopril, amlodipine, atenolol, hydralazine, and hydrochlorothiazide. Facility physician orders mirrored these medications, but the evening doses of atenolol and hydralazine on the day of admission were not given, and the following day the resident did not receive hydrochlorothiazide, lisinopril, or the morning doses of amlodipine, hydralazine, and atenolol. Blood pressure readings during this period showed elevated values, including 193/99, and a late-entry nursing note documented that the resident’s blood pressure was elevated and that medications had just arrived from the pharmacy, even though the facility’s Medication Inventory on Hand report showed all ordered antihypertensives were available. Another resident with Parkinson’s disease with dyskinesia, hypertension, atrial fibrillation, and gait abnormalities had a hospital order for carbidopa-levodopa 25/100 mg three times daily. The facility’s physician orders continued carbidopa-levodopa three times daily, though it was incorrectly indicated for convulsions. The MAR showed that this resident did not receive the evening and bedtime doses of carbidopa-levodopa on the first day and did not receive the bedtime dose the following day, despite the medication being available per the Medication Inventory on Hand report. Nursing documentation for those days did not indicate that the resident refused the medication, and the DON confirmed that the medication was not administered as ordered. A third resident with acute systolic heart failure, acute pulmonary edema, cardiomegaly, and hypertension was discharged from the hospital with an order for carvedilol 6.25 mg twice daily. The facility’s physician order matched this, including parameters to hold the dose if systolic blood pressure was less than 100 or pulse was less than 60. On the day of admission, the resident’s blood pressure and heart rate were within the parameters for administration, but the evening dose of carvedilol was not given according to the MAR. Nursing notes did not document any refusal of the medication, and the Medication Inventory on Hand report showed carvedilol was available. The DON verified that this resident’s medication was also not administered per physician orders. Facility policies required medications to be administered according to written physician orders and directed staff to use on-hand medication supplies when pharmacy medications were not yet available.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The deficiency involves the failure to ensure a resident was free from significant medication errors when insulin pens were not primed according to manufacturer instructions prior to administration. The resident had type 2 diabetes mellitus, was moderately cognitively impaired, and had physician orders for multiple insulin regimens, including insulin lispro via sliding scale, a scheduled daily dose of insulin lispro, and a morning dose of Lantus. The resident’s care plan identified a risk for complications and blood glucose fluctuations related to diabetes and insulin use, with an intervention to administer insulin as ordered. On the day of observation, an LPN checked the resident’s blood sugar, which was 332, and confirmed the resident had eaten 100% of breakfast. The LPN then removed the resident’s lispro and Lantus insulin pens from the medication cart, dialed the lispro pen to 34 units and the Lantus pen to 50 units, and did not prime either pen before dialing in the doses. The LPN proceeded to administer both insulin injections without priming. In a subsequent interview, the LPN confirmed that she had not primed the insulin pens prior to administration. Manufacturer instructions for the KwikPen specified that the pen must be primed before each injection to remove air and ensure proper function, outlining specific steps to select 2 units, hold the pen needle-up, tap to collect air bubbles, and push the dose knob until insulin is seen at the needle tip before dialing the prescribed dose.
Failure to Administer Ordered Cancer Medication and Document Missed Doses
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when ordered doses of Ibrutinib, a targeted cancer medication for lymphoma, were not administered and lacked documented justification. The resident, who had intact cognition and diagnoses including small B-cell lymphoma, difficulty in walking, need for assistance with personal care, and cardiomegaly, was admitted and later discharged in January. Physician orders directed Ibrutinib 140 mg, three capsules by mouth at bedtime, with one order active from early January until mid-January and a subsequent order active from mid-January with a specified hold period and later discontinuation. Review of the MARs showed that Ibrutinib was not given on multiple dates outside the ordered hold period, and the medical record contained no evidence explaining these missed doses. In an interview, the DON stated that the pharmacy did not have the medication available and that she believed the oncologist had stopped it, but she confirmed that this information was not documented in the medical record, contrary to the facility’s policy requiring medications to be administered in accordance with written prescriber orders. This deficiency was cited as non-compliance under Complaint Numbers 2786595 and 2704190.
Failure to Prevent Significant Medication Errors for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, affecting four residents reviewed for medication administration. One resident with cerebral infarction, left hemiplegia, mood disorder, HTN, and epilepsy was seen at Urgent Care for a widespread rash and excoriation, where Keflex and Diflucan were ordered for a fungal skin infection and candidal intertrigo. The resident returned to the facility with these new orders, but the medical record contained no documentation that Keflex was ever administered as ordered, which was confirmed by the DON. Another resident with DM, Down’s syndrome, Hirschsprung’s disease, morbid obesity, and an indwelling catheter had purulent and grey-green drainage from the catheter site and complained of pain with urination. A UA with reflex culture was ordered, and the culture later showed greater than 100,000 pseudomonas, with a handwritten physician order on the report for Bactrim DS twice daily for seven days. Review of the MAR for that month showed no documentation that Bactrim was administered, and the MDS nurse confirmed the antibiotic was not given as ordered for the urinary tract infection. A third resident with breast cancer, HTN, major depressive disorder, and osteoarthritis had an oncology order and prescription for Verzenio 150 mg PO twice daily for cancer treatment. The resident later told nursing staff she was supposed to be on a new oncology medication, and the oncology office was called with a message left, but there was no documented follow-up or clarification. Subsequent oncology documentation showed the resident still had not received Verzenio, and the drug was not ordered by the facility physician or administered until several weeks after the original prescription date. A fourth resident with acute and chronic respiratory failure with hypoxia, type 2 DM with hyperglycemia, and CKD stage 3 had insulin orders specifying administration only when blood sugar exceeded certain thresholds, yet insulin doses of 18 units and 2 units were administered on multiple dates when blood glucose values were below the ordered parameters. A nurse interview verified that insulin had been given outside the prescribed parameters.
Plan Of Correction
F760 Residents are Free of Significant Med Errors The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #51 is no longer in the facility. Resident # 10 received an order from a visit to urgent care, Keflex, that was never taken off and 3/18/26 the wound CNP stated to not take off the Keflex order but continue with Diflucan instead due to the diagnosis of fungal rash on 3/18/26. Resident #10 was assessed by the wound CNP, and the rash is improving per wound CNP on 4-7/26. Resident #3 has blood sugar parameters for insulin coverage the previous order was revised by ADON PA on 3/27/26. Resident assessed by MDS on 4-9-26-26 with blood sugars stable over the last month. Staff have been in-serviced, and audits support the resident is receiving correct doses of insulin. ADON reviewed and revised blood sugar orders 3/27/26 Resident #53 is no longer in the facility How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents in the facility have the potential for the same practice. An audit of all orders on 3-19-26 ensures orders are correct and medication is in place. Parameters for glucose administration reviewed and revised 3/27.26 by ADON. A sweep of antibiotics prescribed was completed 3/25/26 with all having a diagnosis and stop date. This was completed by DON. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee in serviced nursing staff to 1. Retrieve and review any orders from appointments 2. Monitor closely and follow parameters set for insulin coverage. 3. To medicate residents within the accepted standards of practice, applying state local and standard laws. also Nurses were in serviced on what a significant med error is and details of antibiotic stewardship including diagnosis to support the antibiotic. Completed 4/9/26 How the corrective action will be monitored to ensure the deficient practice will not recur. A daily audit is in place done by DON or designee began on 3/26/25 to review MARs to ensure insulin had not been administered outside parameters. an audit begun 3/31/26 to review orders received from all appointments are written per DON/designee, an audit began 3/31/26 to ensure a diagnosis is in place to support the antibiotic order per unit manager and an audit begun 3/31/26 to verify labs have written orders DON/designee. All audits listed are being done 5xaweek X 4 audits and will ensure diagnosis will support a diagnosis to support insulin administration, labs have orders in place, orders from appointments are taken offand insulin is given within parameters. weeks with oversight submitted to QAPI committee weekly. Concerns identified will be corrected and staff reeducated.
Failure to Administer Medications in a Safe and Timely Manner
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in a safe and timely manner for one resident. The resident was admitted for aftercare following explantation of a hip joint prosthesis and had diagnoses including infection and inflammatory reaction due to orthopedic prosthetic devices, acute embolism and thrombosis of deep veins, type II diabetes mellitus, and lumbosacral radiculopathy. The most recent MDS assessment documented that the resident was severely cognitively impaired, rarely or never understood, had no behaviors, and did not reject care. Physician orders included Seroquel (quetiapine fumarate) 12.5 mg via J-tube three times daily for bipolar disorder and ciprofloxacin 750 mg via J-tube every 12 hours for infection. Review of the medication administration audit report showed that on three consecutive days, the 9:00 A.M. doses of Seroquel and ciprofloxacin were administered several hours late: at 12:59 P.M., 12:17 P.M., and 12:32 P.M., respectively. In interview, the DON stated that nurses are expected to administer medications within one hour before or one hour after the scheduled time and confirmed that these medications were given outside the facility’s parameters for safe medication administration. Resident Council minutes from February and March documented resident complaints about medications being administered late. The facility’s policy on documentation of medication administration required that administration be documented immediately after it is given.
Failure to Prevent Significant Medication Errors and Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, including administering controlled substances without active orders and failing to administer ordered medications on multiple occasions. One resident with severe psychiatric and neurological diagnoses had PRN orders for morphine sulfate and lorazepam that were discontinued early in the month, with no subsequent active orders. Despite this, controlled substance records showed lorazepam doses documented on two dates later in the month and morphine doses documented on three dates, including the day of the resident’s death, all without active physician orders. Entries on the narcotic logs were illegible. Hospice documentation indicated that a hospice RN visited the resident due to lethargy and minimal responsiveness, discussed medication administration with an LPN, and noted that lorazepam and morphine were administered during the visit. Electronic triage messages showed the LPN informed the hospice NP that the lorazepam order was not active, requested that it be reinstated and increased, and acknowledged that the resident had not been receiving the medication, yet also indicated that medications were on hand and had been given on specific dates. Additional deficiencies were identified for a resident with glaucoma and related eye pressure issues whose multiple ophthalmic medications and an oral medication for high eye pressure were ordered for administration at 9:00 P.M. and twice daily. Review of the MAR for this resident showed that several 9:00 P.M. doses of Latanoprost, Rhopressa, Brimonidine Tartrate, Dorzolamide-Timolol, and Methazolamide were not administered on multiple dates in the same month. The Regional Clinical Director confirmed that these medications were not given at the ordered times on the identified dates. The resident was documented as cognitively intact on the MDS assessment. A further deficiency involved a cognitively intact resident with hypertensive heart disease with heart failure, intervertebral disc degeneration, and chronic pain syndrome who had an order for Eliquis 5 mg at 9:00 P.M. The MAR showed that this anticoagulant was not administered on multiple specified 9:00 P.M. doses in the same month, and the Regional Clinical Director verified the missed doses. Another resident with hemiplegia, epileptic seizures, vascular dementia, and severe cognitive impairment had a long-standing order for topiramate 50 mg daily at 9:00 P.M. for epilepsy. The MAR revealed that the 9:00 P.M. doses of topiramate were not administered on multiple dates in the same month, and the Regional Clinical Director confirmed these missed doses. The facility’s medication administration policy required staff to verify the right resident, medication, dosage, time, and route before administration, but the documented omissions and administration of medications without active orders demonstrate that this process was not consistently followed.
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