Significant Medication Errors Due to Reordering Failures and Communication Breakdowns
Summary
The facility failed to ensure that residents were free from significant medication errors, resulting in actual harm to one resident and potential harm to another. One resident with a history of traumatic brain injury and epilepsy did not receive the physician-ordered anti-convulsant medication Vimpat for three consecutive doses due to a breakdown in the medication reordering process. The medication was not available because the required prescription was not received by the pharmacy, as the facility's fax machines were not functioning and staff did not follow up to confirm receipt or notify the physician of the missed doses. This resident subsequently experienced severe clonic tonic seizures, required emergency medical intervention, intubation, and transfer to a neuro ICU for ongoing care. Another resident with a diagnosis of stable burst fracture and paraplegia did not receive a scheduled Fentanyl transdermal patch for pain management. The medication was not administered because the facility failed to send the required prescription to the pharmacy, despite the pharmacy indicating that prior authorization was not the cause of the delay. The resident reported significant pain as a result of not receiving the medication. Staff interviews confirmed a lack of understanding and inconsistent practices regarding the reordering of narcotic medications, contributing to the missed doses. Documentation revealed that staff did not consistently document or communicate missed medication doses to physicians, and there was confusion among both facility and agency nurses about the correct procedures for reordering medications, especially when technical issues such as fax machine failures occurred. The facility's policies required medications to be administered safely and as prescribed, but these were not followed, leading to significant medication errors affecting at least two residents.
Removal Plan
- The facility pharmacy was contacted and delivered Resident #63's Vimpat to the facility.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to discuss the root cause analysis of Resident #63 not receiving Vimpat, staff education, and ongoing medication audits. The Administrator, DON, ADON, Social Services, Minimum Data Set Nurse, and Medical Director were in attendance.
- Regional Director of Clinical Services educated the DON, ADON, and Unit Manager on re-ordering resident medications.
- The DON and ADON completed a whole house audit to ensure all in-house residents had all ordered medications available.
- The Administrator/designee educated the nurses who were currently working on re-ordering of medications and the procedure if the fax machine was not functioning properly. All remaining nurses would be educated prior to the beginning of their next shift. Nursing leadership would add education to the nursing agencies the facility utilized to educate their staff on the facility's procedure of re-ordering medications and what to do if the fax machine was not working. Education would also be added to orientation for all new hire nurses. The facility also had a plan in place to hire a unit manager for night shift supervision.
- The Administrator checked the facility fax machines and all three were in working order.
- The DON/designee would audit all resident medications three times weekly for four weeks then two times weekly for two weeks, then one time for two weeks to ensure all in-house residents have all ordered medications available. Any concerns identified would be reviewed in Ad Hoc QAPI by the interdisciplinary team.
- Nursing leadership would ensure all resident medications would be re-ordered when no less than five days remaining of the medication. Nursing leadership would be responsible for providing any prior authorization requests to the physician and/or nurse practitioner and following up to ensure the prior authorization request was returned to pharmacy timely.
- Staff would contact the Administrator or nursing leadership to inform them if the fax machine is not working. If a prescription was needed, the physician and/or nurse practitioner would be contacted by staff or nursing leadership to request the prescription. Staff/nursing leadership would follow up with pharmacy to ensure the physician order was received.
Penalty
Resources
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Failure to follow warfarin orders led to significant med errors for a cognitively intact resident with a mechanical heart valve and hx of cerebral infarction. MAR review showed missed doses in one month and incorrect dosing and omissions in another, and the DON confirmed the orders were not followed.
A resident with a seizure disorder did not receive the ordered bedtime phenytoin dose after admission because the order was not entered into the system, and the MARs reflected only the once-daily dose. The resident later had a seizure and was transferred to the hospital, where records documented status epilepticus, a subtherapeutic phenytoin level, and active infection. Interviews confirmed the missed order and that the resident had been receiving only one daily dose.
Two residents experienced significant medication errors. One resident with COPD and other chronic conditions did not receive ordered Lasix or a daily nasal spray during observed med pass, and the RN signed the meds as given despite omitting them. Another resident with diabetes did not receive ordered blood sugar checks and Humalog insulin on time; an LPN was hours late with the lunch check and dose, then tried to return close to dinner for another check, which the resident refused. The facility policy required meds to be given safely and within the prescribed time frames.
A facility medication pass failed when multiple residents on one hall did not receive ordered morning meds, including insulin, pain meds, seizure meds, anticoagulants, and BP meds. MARs lacked documentation of administration, some required blood glucose, BP, pulse, or weight checks were not completed, and residents reported pain, weakness, and concern about missed meds. The DON acknowledged the coverage issue and stated the missed 8 a.m. meds were significant medication errors.
A resident received 2.5 mL of Morphine Sulfate PO instead of the ordered 0.25 mL dose after a CNA/MA medication error. The resident then developed decreased O2 levels, lethargy, respiratory distress, and apnea, and required Narcan. The EMR lacked documentation of post-error assessments, call times to hospice or Ecare, an incident report, and a documented physician order for the Narcan given by hospice.
A resident with a BIMS score of 13 received oral sertraline solution without being diluted as required by the manufacturer. The MAR showed the medication was given, but the package instructions stated it must be mixed with 4 oz of approved liquid before use. After the dose, the resident complained of a burning tongue and sore throat, and staff and the NP confirmed the medication error.
Failure to Follow Warfarin Orders
Penalty
Summary
The facility failed to ensure that physician orders were followed for Resident 93, resulting in significant medication errors involving warfarin. Resident 93 was cognitively intact, received an anticoagulant, and had diagnoses including cerebral infarction and a mechanical heart valve requiring lifelong blood-thinning medication. A review of the resident’s MAR showed that warfarin ordered in December 2025 was not administered from December 18 through December 21, 2025. In addition, physician orders in May 2026 directed specific warfarin doses on alternating days, but the MAR showed that staff administered 7.5 mg on May 12 and May 14, and no warfarin was given on May 13 or May 15. The DON confirmed that a medication error occurred in December and that the warfarin orders were not followed in May 2026.
Missed Antiseizure Medication Order Led to Seizure Event
Penalty
Summary
The facility failed to ensure that a resident with a seizure disorder received physician-ordered phenytoin after admission. The resident’s hospital discharge orders reflected phenytoin oral suspension 25 mg/mL, 4 mL daily and 8 mL at bedtime, but the facility’s physician orders only reflected phenytoin oral suspension 100 mg/4 mL, 4 mL once daily. The March and April MARs showed administration of the once-daily dose, but did not reflect the ordered bedtime dose for 27 days. The resident had a history of unspecified convulsions and severe cognitive impairment, and the care plan identified seizure disorder with an intervention to give seizure medication as ordered by the doctor. The hospital record showed a phenytoin level of 21.43 mcg/mL before admission. The facility record also showed that the resident later had a seizure lasting approximately 4 minutes and was transferred to the hospital. The hospital record from the transfer documented status epilepticus, subtherapeutic phenytoin level of 2.4, and active infection including UTI/sepsis and possible pneumonia. In interviews, the LVN stated the resident received only one daily dose and that the bedtime Dilantin order had been missed when entered into the system. The DON stated the admitting nurse forgot to place the correct order and that the resident only received the once-daily dose because the bedtime dose was not entered.
Significant medication errors with missed ordered medications and delayed insulin coverage
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, affecting two residents reviewed for medication administration. Resident #73 had diagnoses including COPD, multiple sclerosis, hypertension, and peripheral vascular disease, and was noted to have impaired cognition on a Quarterly MDS assessment. His orders included Lasix 80 mg by mouth in the morning and fluticasone propionate nasal spray once daily for nasal congestion. During observed medication administration, an agency RN obtained his morning medications but omitted both the fluticasone propionate nasal spray and the Lasix tablet, then signed them off as administered. When interviewed afterward, the RN stated she had not given the nasal spray because she thought he usually refused it, but she had not offered it to him, and she stated she had missed the Lasix order. The resident stated he always took his nasal spray and that it was not given that morning. Resident #32 had diagnoses including diabetes, anemia, depression, and cellulitis, and was cognitively intact. Her orders required blood sugar checks before meals and at bedtime, with Humalog insulin given per sliding scale coverage. On 05/13/26, former LPN #649 documented a blood sugar of 256 at 7:00 A.M. with 8 units of Humalog given, and a blood sugar of 290 at 11:00 A.M. with 8 units of Humalog given, but the blood sugar summary showed the first documented blood sugar was at 8:30 A.M. and the next was not until 3:20 P.M., with no dinner blood sugar documented. The resident reported that the LPN did not check her breakfast or lunch blood sugar or give insulin when due, and that he later attempted to return close to dinner to check again and give another dose, which she refused because it was too close together. The former LPN acknowledged he was three to four hours late with the lunch blood sugar and insulin, said he got behind during the day, and confirmed he did not notify the DON or physician that the blood sugar and/or insulin was not administered on time.
Missed Morning Medications and Insulin Pass
Penalty
Summary
The facility failed to administer physician-ordered medications during the morning medication pass on 5/10/26, resulting in significant medication errors for eight residents on the 100 hall. The report states that R1, R2, R3, R4, R5, R6, R7, and R8 did not have nurses’ initials documented on their May 2026 MARs for multiple ordered medications that were due that morning. The missed medications included insulin, pain medications, antihypertensives, anticoagulants, anticonvulsants, diuretics, and other routine medications ordered for chronic conditions. R5, who had a BIMS score of 15 and no cognitive impairment, had ordered oxycodone/APAP for pain related to rheumatoid arthritis, osteoarthritis, and scoliosis, along with benazepril for hypertension. The pain assessment scheduled for 8:00 am was not documented as completed, and the MAR did not show the morning dose given. R5 stated she had extreme pain on Mother’s Day, rated it 10/10, and said she did not receive her pain medication when scheduled. The controlled substance proof of use sheet showed the oxycodone/APAP was not removed until the 12:00 pm dose, confirming no 8:00 am dose was administered. R1, R2, and R3 each had ordered insulin with meals and other routine medications, but no blood glucose checks were documented at the morning medication time to determine whether sliding-scale insulin was needed. R1’s first blood sugar check was not completed until after lunch and was 441 mg/dL; the MAR documented 12 units of insulin based on that later reading, and the record did not show provider notification for a blood glucose greater than 400. R2 and R3 also had multiple morning medications not documented as administered, including insulin and other chronic medications. R2 stated the morning was the worst because there was no nurse and she did not get insulin or an accu-check, and R3 had no documented blood glucose measurement to determine insulin dosing. R4, R6, R7, and R8 also had multiple morning medications not documented as given. R4’s missed medications included seizure medication, pregabalin, lamotrigine, and furosemide; R4 stated she was upset because she was supposed to take pain, seizure, and blood pressure medication. R6 had missed Norco, clopidogrel, torsemide, and eslicarbazepine, and also had no documented daily weight; she stated she did not get her medications and had significant leg pain. R7’s missed medications included tramadol, Eliquis, metoprolol, and losartan, with no corresponding blood pressure or pulse documented for the metoprolol hold parameters. R8’s missed medications included aspirin, amlodipine, metoprolol succinate, and torsemide, and the daily weight was not documented as completed. The DON acknowledged the medication errors occurred because of nurse coverage issues on the 100 hall, and the facility policy states medications are to be administered as prescribed with sufficient staff and a medication distribution system to ensure safe administration without unnecessary interruptions.
Significant morphine dosing error with respiratory depression
Penalty
Summary
The provider failed to ensure a resident was free from a significant medication error when a CNA/medication aide administered 2.5 mL of Morphine Sulfate orally instead of the ordered 0.25 mL dose. The resident had an order for Morphine Sulfate 100 mg/5 mL to be given as needed for pain or shortness of breath. The incorrect dose was 2.25 mL over the prescribed amount. After the incorrect dose was given, the resident developed decreased oxygen levels, lethargy, respiratory distress, and apnea. The resident required Narcan after the medication error. The record states that Ecare, the DON, hospice, and nursing staff were notified, and the resident was monitored after the event. The hospice RN later reported that the resident had shallow breathing with pauses up to 20 seconds and oxygen saturation dropping into the mid to lower 80s before Narcan was ordered. The resident's EMR did not document vital signs or assessments completed after the morphine error, and there was no documentation of the time calls were made to hospice or Ecare. There was also no incident report completed for the medication error, no physician's order documented for the Narcan given by hospice, and the verbal order for Narcan was not entered into the MAR with the ordering physician's name. The DON stated she expected a nursing assessment with respiratory rate, blood pressure, pulse, oxygen, temperature, and orientation or alertness documented after a narcotic medication error.
Undiluted Zoloft Oral Solution Administered
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when staff administered undiluted Sertraline Hydrochloride (Zoloft) oral solution. The resident was admitted after joint replacement surgery and had a BIMS score of 13, indicating cognitive intactness. The facility policy required medications to be administered according to the manufacturer’s specifications, including proper preparation and administration of the drug. The resident had an order for Sertraline HCl oral concentrate 20 mg/ml by mouth, and the MAR showed the medication was administered on the day of the incident. The medication package and prescribing information stated that Zoloft oral solution must be diluted before use and mixed with 4 ounces of water, ginger ale, lemon/lime soda, lemonade, or orange juice only. Despite these instructions, the medication was given without being mixed in liquid. After administration, the resident complained of a burning tongue and sore throat, and the incident was documented as liquid Zoloft not mixed in liquid. The resident’s representative reported that the resident said her throat was burning because the nurse did not mix the medication, and the resident was taken to the emergency room for evaluation and then home. Interviews with nursing staff and the NP confirmed the medication had been administered without dilution and that the resident experienced mouth and throat discomfort afterward.
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