Pharmacist Failed to Identify and Report Repeated Medication Administration Errors
Summary
A licensed pharmacist failed to identify and address repeated medication administration errors during monthly drug regimen reviews for a resident prescribed Midodrine for hypotension. The resident had specific parameters for administration, requiring the medication to be held if systolic blood pressure exceeded 120 or diastolic exceeded 80. Despite these parameters, the medication was administered outside of the prescribed limits 38 times in January, 44 times in February, and 35 times in March. The pharmacist's monthly reviews did not document these errors, and the majority of the errors went unreported to facility leadership. The pharmacist only partially acknowledged some errors in a February recommendation to nursing staff, listing a small sample of dates but not the full extent of the errors. No recommendations or notifications were made regarding the errors in January or March. Interviews with the pharmacist revealed she did not consider the errors clinically significant and believed that education provided to nursing staff would resolve the issue, though no such education had actually occurred. The pharmacist's monthly summary reports for all three months stated that no medication errors were noted. Facility leadership, including the DON, Unit Manager, Staff Development Nurse, and Administrator, were unaware of the medication errors until informed during the survey process. None of the nursing leadership had received reports or recommendations regarding the errors, nor had any education been provided to staff about medication parameters. The Medical Director confirmed that the pharmacist should have reported the errors as soon as they were discovered. The resident involved did not experience any significant outcome as a result of the errors.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with multiple comorbidities, including DM, CKD, morbid obesity, and mobility impairment, had a PRN order for Hydroxyzine Pamoate 25 mg. The consulting pharmacy later recommended discontinuation of this drug, and the physician signed to discontinue it, but nursing staff continued to administer the medication and the order remained active on the MAR for several weeks afterward. This resulted in the resident receiving doses of Hydroxyzine despite the documented decision to stop the medication, contrary to facility policy requiring medications to be administered in accordance with prescriber orders.
The facility did not ensure timely and appropriate action on pharmacist drug regimen reviews for two residents. For one resident with multiple comorbidities receiving doxycycline, magnesium oxide, and ferrous sulfate, the pharmacist and physician agreed to separate administration times to improve absorption, but nursing staff did not change the MAR administration time for magnesium oxide as ordered. For another cognitively intact resident with DM, mental health diagnoses, paraplegia, and breast cancer, pharmacy recommendations for a gradual dose reduction of amitriptyline and clarification of two PRN lorazepam orders received limited physician responses and no further documented follow-up, despite facility policy requiring timely review, documentation of actions or rationale, and transcription of new orders.
A resident with multiple chronic conditions and a documented allergy to metformin was prescribed and administered metformin for 24 days without proper identification or intervention by nursing staff or the consulting pharmacist. The allergy was inconsistently documented in the care plan, and neither the resident's representative nor the physician was notified of the new order or the allergy. The pharmacy's monthly review failed to note the irregularity, and staff interviews revealed gaps in communication and adherence to facility policy regarding allergy checks and reporting.
Two residents did not receive prescribed medications as ordered due to delays in pharmacy delivery and lack of timely follow-up by nursing staff. One resident experienced a delay in starting an antibiotic for a UTI, while another missed several doses of an antianxiety medication, with insufficient documentation and delayed action to resolve the issue.
A resident with a UTI did not receive the prescribed Cipro antibiotic as ordered due to the facility's failure to respond to a pharmacy alert about a drug interaction with tizanidine. The pharmacy withheld the medication pending clarification, but the facility did not act on the notification, resulting in the resident missing several scheduled doses. Documentation showed only partial administration, and the issue was not communicated to the nurse practitioner until days later.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Timely Implement Pharmacy and Physician Discontinuation of PRN Hydroxyzine
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely implementation of pharmacy recommendations to discontinue a medication after physician approval. A resident admitted with diagnoses including a displaced right humerus fracture, gait and mobility abnormalities, type II diabetes mellitus, morbid obesity, and chronic kidney disease had a physician order dated 01/27/26 for Hydroxyzine Pamoate 25 mg to be given orally once daily as needed. The five-day admission MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and documented that the resident was receiving a diuretic, opioid, antiplatelet, and antidepressant. On 02/16/26, the consulting pharmacy recommended discontinuation of Hydroxyzine Pamoate 25 mg, and on 02/20/26 the physician reviewed and agreed with this recommendation, signing to discontinue the medication. Despite the physician’s discontinuation decision, review of the February and March 2026 MARs showed that the Hydroxyzine Pamoate order remained active and the medication continued to be administered. The MAR for February 2026 documented administration of Hydroxyzine Pamoate 25 mg on 02/25/26, and the March 2026 MAR documented administrations on 03/06/26 and 03/11/26. The order itself was not discontinued until 03/16/26. During an interview on 03/17/26, the Regional Nurse confirmed that the pharmacy recommendation to discontinue the medication was made on 02/16/26, the physician signed to discontinue it on 02/20/26, but the medication continued to be given on the above dates and the order remained in place until mid-March. Facility policy on medication administration stated that medications are to be administered in accordance with prescriber orders, which did not occur in this case.
Failure to Act on Pharmacist Drug Regimen Reviews and Orders
Penalty
Summary
The facility failed to ensure appropriate and timely response to pharmacist drug regimen reviews for two residents. For one resident with acute osteomyelitis, DM, PVD, CHF, and anemia, the pharmacist recommended on 12/09/25 that doxycycline administration be separated by at least two hours from magnesium oxide and ferrous sulfate to optimize absorption. The physician reviewed and signed this recommendation on 12/10/25. However, review of the December 2025 MAR showed the resident continued to receive doxycycline at 8:00 A.M. and 8:00 P.M., magnesium oxide at 8:00 A.M., and ferrous sulfate at 12:00 P.M., with no documentation that the magnesium oxide administration time was changed as recommended and ordered. The DON confirmed that staff had not changed the magnesium oxide administration time in accordance with the pharmacy recommendation and physician order. For another cognitively intact resident with type 2 DM, anxiety disorder, major depressive disorder, schizoid personality disorder, paraplegia, and malignant neoplasm of the breast, pharmacy recommendations dated 01/27/26 included a gradual dose reduction trial for amitriptyline and addressing two PRN lorazepam orders. The physician documented on the recommendation that dose reduction was contraindicated due to likely increased distressed behavior and added handwritten notes disputing the characterization of the resident as "psych." For the lorazepam recommendation, the physician renewed the duration of therapy for 14 days and again added handwritten notes referencing hospice and disputing "psych" labeling. The DON verified there had been no additional physician follow-up for these January 2026 pharmacy recommendations. Facility policy stated that physician recommendations from medication regimen reviews are to be distributed to the physician within two working days, reviewed within 30 days, and documented with actions taken or rationale for no change, with new orders transcribed and forwarded to pharmacy.
Plan Of Correction
F756 Drug Regimen Review. The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #2 recommendation for a change in magnesium order was not needed as the antibiotic that was a conflict is no longer ordered.MD notified 3/31/26. Resident #4 MD stated a dose reduction for amitriptyline is contraindicated and will not make a change at this time for fear of worsening of condition MD order 4/1/26. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Like residents, are residents in the facility who are reviewed by the pharmacy consultant. A sweep of the pharmacy recommendations in coordination with the medical director resulted in all recommendations have been reviewed and signed off on 3-26-26. The sweep went back to February 2026.conducted by ADON. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur. DON and ADON in-service by corporate nurses to obtain follow-up to the pharmacy recommendations in a timely manner. Also, in-service to assist MD when the resident has a psychiatrist or counselor. In-service was done on 3-27-26. MD inservice by ADON on 4/1/26 to complete pharmacy recommendations timely. How the corrective action will be monitored to ensure the deficient practice will not recur. DON is auditing, starting 4/1/26, for completed responses with signatures from MD and nurses, follow-up to ensure all recommendations are responded to by MD within a week after receiving recommendations,and the pharmacy recomentations are written. monthly X2, and submitting findings to QAPI committee. If concerns are noted, DON will approach MD and ADON to correct the issue and to prevent further issues.
Failure to Identify and Address Resident Allergy During Medication Review
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's allergy to metformin was properly identified and addressed during the monthly medication regimen review by the consulting pharmacist. The resident, who had multiple diagnoses including type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia, had a documented allergy to metformin in the allergy alert profile. However, this allergy was not consistently reflected in the resident's care plan, and a physician order for metformin was entered and administered despite the known allergy. The medication administration record showed that metformin was given daily for 24 days by four different nurses, even though the allergy was documented in the resident's profile and flagged in the electronic physician order system. There was no documentation that the resident's representative or the physician was notified about the new order for metformin or the resident's allergy to the medication. Additionally, the pharmacy's monthly review did not document the irregularity of the metformin order in the presence of the allergy, and the consulting pharmacist assumed the allergy had been previously addressed without further investigation. Interviews with facility staff and pharmacy representatives revealed a lack of communication and follow-up regarding the allergy and the medication order. The Director of Nursing confirmed that nurses should check for allergies before administering medications and that the resident's representative should have been notified. The consulting pharmacist acknowledged that the allergy should have been investigated further during the monthly review. Facility policies required pharmacists to review medication regimens and report irregularities, as well as evaluate new medication orders for allergies, but these procedures were not followed in this case.
Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were available for administration to two residents, as evidenced by record reviews and staff interviews. One resident, admitted with multiple diagnoses including acute respiratory failure, dementia, and a recent urinary tract infection (UTI), experienced a delay in receiving a prescribed antibiotic (Cefdinir) for the UTI. Although the physician ordered the medication after reviewing laboratory results, documentation showed that the medication was not available from the pharmacy on the evening it was ordered, resulting in a delay until the following morning. There was no nursing note explaining the missed dose, and the delay was confirmed by the Regional Director of Clinical Service. Another resident, admitted with conditions such as pneumonia, esophageal cancer, and anxiety disorder, did not receive a prescribed antianxiety medication (Alprazolam) on several occasions. The medication was marked as pending delivery, and nursing notes indicated that the provider and pharmacy were contacted only after multiple missed doses. There was a lack of documentation regarding the missed doses on some days, and no evidence of timely action to obtain the medication. These findings were verified by facility leadership, confirming delays in medication administration for both residents.
Failure to Respond to Pharmacy Drug Interaction Alert Resulting in Missed Antibiotic Doses
Penalty
Summary
The facility failed to respond in a timely manner to a pharmacy notification regarding a drug interaction for a resident who was prescribed Cipro for a urinary tract infection (UTI). The resident, who was cognitively intact and admitted with diagnoses including UTI and urinary retention, had a new order for Cipro. The pharmacy identified a potential drug interaction between Cipro and tizanidine and notified the facility, requesting clarification or a change in medication. Despite this notification, the pharmacy did not receive a response from the facility, and as a result, did not send the Cipro to the facility. During this period, documentation showed that the resident received only three out of ten scheduled doses of Cipro, with some doses being documented as administered from prepackaged medications. The Certified Pharmacy Technician confirmed that the medication was withheld pending clarification, and the DON acknowledged that the pharmacy's recommendation was not completed. The nurse practitioner was not made aware of the missed doses until several days later. The breakdown in communication and failure to act on the pharmacy's alert led to the resident not receiving the prescribed antibiotic as ordered.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
