High Medication Error Rate Due to Staffing Issues
Summary
The facility failed to ensure that the medication error rate was below 5%, resulting in a 15% error rate during a medication pass observation. This deficiency affected 16 out of 24 residents, with 27 errors out of 177 opportunities. The errors primarily involved the late administration of medications, which were supposed to be given by 9:00 AM but were administered after 11:00 AM. This delay in medication administration was observed for multiple residents, including those with serious medical conditions such as epilepsy, Parkinson's disease, Alzheimer's disease, and other chronic illnesses. The report highlights specific instances where residents did not receive their medications on time, leading to potential health risks. For example, a resident with epilepsy did not receive their anti-seizure medications, Keppra and Phenobarbital, on time. Another resident with Parkinson's disease did not receive their Gabapentin and Ropinirole as scheduled. These delays were documented in the residents' Medication Administration Records (MARs) and progress notes, with notifications made to physicians, although the medications were still administered late. The deficiency was exacerbated by staffing issues, as the scheduled medication aide did not report for duty, leaving only one medication aide to cover multiple hallways. This situation led to significant delays in medication administration, as observed and reported by residents and staff. The Assistant Director of Nursing (ADON) and other staff members attempted to manage the situation by taking on additional responsibilities, such as passing medications and checking vital signs, but these efforts were insufficient to prevent the high medication error rate.
Penalty
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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 that an LPN committed three medication errors during 36 administration opportunities, resulting in a medication error rate above 5%. A resident with an order for crushed medications received Ingreeza prepared by softening the capsule in pudding instead of sprinkling the capsule contents as ordered. The same resident did not receive ordered Flonase nasal spray and olopatadine eye drops because the medications were not available. The ADON confirmed the improper Ingreeza administration as a significant medication error, and the NHA acknowledged that the facility exceeded the allowable medication error rate.
Surveyors identified that the facility failed to keep its medication error rate below 5%, finding three errors among 26 opportunities (11.45%). One resident with constipation did not receive a prescribed daily dose of polyethylene glycol when an RN mixed the laxative, placed it on the over-bed table, administered other meds, and left the room without giving it. Another resident with constipation received only part of a polyethylene glycol dose when an RN gave a single drink of the dissolved laxative, then left the remaining medicated solution at the bedside and exited the room. A third resident with GERD, ordered calcium carbonate 600 mg each morning, was administered 1000 mg when an RN used tablets labeled 1000 mg and later acknowledged not realizing a 600 mg strength existed.
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 found that the facility’s medication error rate exceeded 5% after observing an RN administer a morning medication pass in which Duloxetine 60 mg, ordered to be given at bedtime for depression, was instead given in the morning, and Famotidine 20 mg, ordered once daily in the morning for GERD, was not observed being administered but was signed out as given on the MAR. These administration and documentation errors contributed to a calculated medication error rate of 6.45%.
Surveyors observed multiple medication administration errors resulting in a 14% error rate. One resident’s RN mishandled oral medications by touching pills with bare hands while searching for a diuretic, administered the diuretic after the resident had requested it be held, documented it as held on the MAR, and omitted an ordered nasal spray that was not available on the cart. The same RN failed to follow insulin lispro pen instructions, including not cleaning the rubber seal, priming the pen incorrectly, and not holding the injection site for the recommended time. For another resident, an RN initially prepared the wrong aspirin formulation (enteric-coated instead of chewable) before recognizing the discrepancy. These events occurred despite a policy requiring adherence to professional standards and accurate MAR documentation.
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 Error Rate Exceeded Due to Omitted and Improperly Administered Medications
Penalty
Summary
Surveyors determined that the facility failed to maintain a medication error rate below 5%, identifying three errors out of 36 medication administration opportunities, resulting in an 8.33% error rate. During a medication pass observation on 4/1/26 at 8:56 a.m., an LPN prepared a 40 mg Ingreeza capsule for a resident with an order for medications to be crushed, by softening the capsule in pudding rather than sprinkling the capsule contents in pudding as ordered. The LPN later confirmed that she did not prepare and administer the Ingreeza in accordance with the ordered method. In the same observation period, the LPN failed to administer the resident’s ordered 50 mcg/actuation fluticasone propionate (Flonase) nasal spray and 1 mg/mL olopatadine ophthalmic solution because these medications were not available. The LPN acknowledged that these medications were not given due to unavailability. The Assistant DON confirmed that the Ingreeza administration constituted a significant medication error, and the Nursing Home Administrator confirmed that the facility did not meet the requirement to remain free of a medication error rate of 5% or greater, based on the three identified errors out of 36 opportunities.
Medication Administration Errors Exceeding Acceptable Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 26 opportunities (11.45%) during medication administration observations. For a resident admitted with constipation, a physician’s order dated 01/06/26 directed administration of 17 grams of polyethylene glycol powder by mouth once daily. On 03/24/26 at 10:00 AM, a nurse mixed the polyethylene glycol in water, brought it to the bedside, placed it on the over-bed table, and then administered other medications and a flavored liquid used to swallow pills. The nurse left the room without giving the polyethylene glycol. When questioned at 10:30 AM, the nurse acknowledged leaving the medication on the table and stated she forgot to administer it because she was nervous; the mixed medication remained on the table in the resident’s room. Another resident with constipation had a physician’s order dated 12/14/23 for polyethylene glycol, one packet by mouth every other day, dissolved in 4–6 oz of fluid. On 03/24/26 at 9:20 AM, a nurse prepared this resident’s medications, including dissolving the polyethylene glycol in water, administered the crushed medications, gave the resident one drink of the polyethylene glycol mixture, then placed the remaining mixture on the over-bed table and left the room. At 10:33 AM, when asked about this medication, the nurse stated she should not have left the drink in the room because it contained medication and that she should have ensured the resident drank all of it. A third resident, admitted with gastroesophageal reflux disease, had a physician’s order dated 03/19/26 for calcium carbonate 600 mg by mouth in the morning as a supplement. On 03/24/26 at 8:45 AM, a nurse prepared and administered calcium carbonate 1000 mg instead. Later that day, review of the medication bottle showed tablets labeled 1000 mg, and the nurse stated she did not think calcium carbonate came in 600 mg tablets and would inform the provider about the dosage.
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.
Medication Administration and Documentation Errors Result in Elevated Medication Error Rate
Penalty
Summary
Surveyors determined that the facility failed to maintain a medication error rate below 5%, with an observed rate of 6.45%. During a medication pass observed at 9:18 AM, a registered nurse administered multiple medications, including Lasix 20 mg, a multivitamin, MiraLAX 17 g, Duloxetine 60 mg, allopurinol 100 mg, carvedilol 3.125 mg, vitamin B12, and lisinopril 5 mg. A subsequent review of the medication administration record at 12:38 PM revealed that Duloxetine 60 mg, ordered as a delayed-release capsule to be given by mouth at bedtime for depression, was instead administered during the morning medication pass. The review also showed an active order for Famotidine 20 mg by mouth once daily in the morning for GERD, which was not observed being administered during the medication pass but was documented on the medication administration record as having been given. These observed discrepancies between physician orders, actual medication administration times, and documentation on the medication administration record constituted medication errors that contributed to the facility’s medication error rate exceeding the 5% threshold.
Medication Administration Errors Resulting in 14% Error Rate
Penalty
Summary
Surveyors identified a medication error rate of 14% (4 errors out of 29 opportunities), exceeding the 5% threshold, related to medication administration practices for two residents. For one resident, an RN prepared oral medications and subcutaneous insulin and brought them to the resident’s room. When the resident asked if her diuretic was in the cup and requested that it be removed so she could take it later, the RN stated that it was present, left the room, and then searched through the medication cup at the cart, touching three pills with bare hands while attempting to identify the diuretic. The RN then returned and administered all medications, including the diuretic, without informing the resident that the diuretic remained in the cup. During the same medication pass, the RN was unable to locate the resident’s ordered nasal spray, stated she would obtain a new one from backup supply, and did not administer the nasal spray. Medication reconciliation later showed the diuretic was documented as “held” even though it was given, and the nasal spray was omitted and not given, and the medication cart lacked the nasal spray. During preparation and administration of the resident’s insulin lispro, the RN did not follow manufacturer instructions: she failed to clean the pen’s rubber seal with alcohol, primed the pen while holding it horizontally instead of with the needle pointing up, and held the injection site for only two seconds, after which a drop of blood appeared at the site. The DON confirmed these steps were inconsistent with expectations and standards of practice. For a second resident, another RN prepared medications and initially dispensed an enteric-coated aspirin 81 mg instead of the ordered chewable aspirin 81 mg, placing it in the medication cup with other medications. When questioned, the RN reviewed the order and acknowledged the aspirin form was incorrect and needed to be replaced with the chewable form. These observed errors and omissions occurred despite a facility policy requiring medications to be administered as ordered, in accordance with professional standards, and with proper verification and documentation on the MAR.
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