Significant Medication Errors Due to Omission and Documentation Failures
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the omission and improper administration of critical medications for two residents. For one resident, Metoprolol and Entresto, both prescribed for hypertension and heart failure, were not administered as ordered on a specific evening. Additionally, upon admission from the hospital, Entresto was not ordered for another resident, despite it being listed on the hospital discharge medication list. This omission was not identified or corrected by the admitting nurse or subsequent staff responsible for medication reconciliation and order entry. The same resident also failed to receive Eliquis, an anticoagulant prescribed for atrial flutter, on eight occasions in a single month. The medication administration record (MAR) showed multiple blanks with no documentation to indicate whether the medication was given or refused. Interviews with nursing staff revealed inconsistent documentation practices, with some staff admitting to forgetting to chart medication administration or not following up on missed doses. There was also a lack of clarity and communication regarding the process for documenting refusals and ensuring that all medications were administered as ordered. The resident who missed multiple doses of Eliquis was later hospitalized and diagnosed with atrial fibrillation with rapid ventricular response, acute on chronic systolic and diastolic heart failure, and a small pulmonary embolus. Staff interviews indicated that the resident was sometimes noncompliant or refused medications, but there was no consistent documentation of refusals or evidence that appropriate notifications were made to the physician or family. The facility's policies required that all medication refusals or omissions be documented in the MAR, but this was not consistently followed, leading to significant medication errors.
Removal Plan
- The administrative nursing team (Director of Nursing, Assistant Director of Nursing and MDS Coordinator) with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations will complete medication order reviews for all residents admitted and re-admitted to ensure no residents are in jeopardy or threat of harm.
- Chart reviews of the remaining residents admitted and re-admitted will be completed by the administrative nursing team with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations to ensure accurate reconciliation of hospital discharge orders/admitting orders to those that were verified with the attending physician and transcribed into the electronic health record.
- Chart reviews will ensure all diagnosis/health conditions of residents is being/has been addressed/noted in the electronic health record.
- The Facility Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator were counseled and provided with an in-service by the Director of Clinical Operations and the Assistant Director of Clinical Operations regarding daily review of admission records, admission order reconciliation, review of 24/72 hour report, and reviewing the missing medication report each morning during the morning meeting process.
- The Facility Administrator will be responsible for ensuring the daily review of the missed medication report, admission record review, admission order reconciliation, and review of the 24/72-hour report. In the absence of the Facility Administrator the Director of Nursing will be responsible.
- All nurses and certified medication aides present at the time of the notification will be provided with in-service training regarding the admission/re-admission process, the admission/readmission medication reconciliation process, transcribing and carrying out physician orders, how to document different scenarios of medications not given (refused, spit out, held for vital signs outside of parameters, etc.), checking the dashboard throughout and at the end of their shift to ensure no medication documentation is missing.
- The staff in-service will be conducted by the Administrative Nursing Team and will continue until all nurses and certified medication aides have been provided with the beforementioned education; the remaining nurses and certified medication aides will be educated prior to beginning their next shift.
- All newly hired nurses and certified medication aides will be educated regarding how to document missed doses, refused doses, and accessing the dashboard to ensure all doses are accounted for before the end of their shift before beginning their first assigned shift.
- A QAPI meeting was conducted with the Medical Director, Facility Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Corporate Director of Clinical Operations, and Assistant Corporate Director of Clinical Operations. The root cause analysis of the alleged deficient practice was reviewed and interventions to correct and prevent future occurrence were discussed.
- The Consultant Pharmacist was contacted by the Corporate Director of Clinical Operations and discussed the alleged deficient practice; it was decided that all new and re-admissions to the facility will be reviewed by a pharmacist with the consultant pharmacy group every Monday, Wednesday and Friday.
- The Consultant Pharmacist will review all residents admitted /re-admitted to the facility. In addition to the regular medication regimen review the consulting pharmacist will reconcile current physician orders to those given from the discharging entity. Upon completion of his/her review, the consulting pharmacist will provide a summary of findings/recommendations to the Director of Nursing, Assistant Director of Nursing and Facility Administrator. Immediately upon receipt of the recommendations the Director of Nursing will ensure any physician recommendations are addressed and carried out.
- The recommendations from the consultant pharmacist will be reviewed during the morning meeting Monday through Friday and the Facility Administrator and Director of Nursing will verify they are complete with a physician acceptance or declination, orders corrected or changed as recommended/agreed to by physician, plan of care updated, and resident/resident representative informed of changes.
- The Corporate Director of Clinical Operations will provide an in-service to the Facility Administrator and administrative nursing staff regarding the review of the pharmacy consultant admission/re-admission drug regimen review/medication reconciliation process that is to be reviewed during the morning meeting every Monday through Friday.
- The facility nursing administration staff (Director of Nursing, Assistant Director of Nursing, and MDS Nurse) with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations will begin a full audit of all resident medication orders.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Significant morphine dose error: An RN administered 0.25 mL (5 mg) of morphine sulfate buccally instead of the ordered 0.1 mL (2 mg) dose to a resident with severe cognitive impairment, Alzheimer’s disease, CAD, and dementia. The RN said she followed the medication box label, while the unit manager confirmed the correct dose was on the EMAR. The resident was assessed afterward and remained unchanged.
An LPN administered Humalog insulin to a resident with stroke, aphasia, and diabetes without priming the insulin pen as required by manufacturer instructions. The LPN dialed the ordered 5-unit dose but did not prime the pen with 2 units before injection, and later stated she was unaware of the need to prime it. The DON confirmed insulin pens should be primed according to the manufacturer's instructions.
A resident with CHF and dysphagia had a medication error when an MA crushed and administered multiple morning meds, including Potassium Chloride ER, despite a provider order that it not be crushed. The facility policy required meds to be given as ordered and prohibited crushing do-not-crush, slow-release, and enteric-coated meds; the record also identified potassium chloride as a high-alert medication.
Two residents experienced significant medication errors when ordered meds were not available or not administered as prescribed. One resident on hospice went more than 24 hours after admission without ordered Morphine for pain and air hunger, while another resident missed multiple doses of a Lidocaine patch and Mirabegron because the meds were out of stock or not obtained from the pharmacy, with the DON confirming the missed doses and unrelieved pain were significant.
A resident with moderately impaired cognition and cerebral amyloid angiopathy had a weekly buprenorphine patch order inaccurately transcribed as Suboxone on the MAR. Staff also applied a new pain patch without removing the old one, leaving two active patches on the resident for several days. The DON stated the admission verification process was not followed and the incident was not investigated.
A resident with DM2 and multiple chronic conditions had an order for daily insulin glargine, but an RN documented that the dose was not given because the medication was unavailable. An LPN stated staff should reorder meds when five doses remain and, if out, notify the provider and pharmacy and use the emergency medication supply system; an RN and the DON confirmed backup insulin was available in a lockbox, and the DON noted there was no documentation explaining the omission.
Significant morphine dose error
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when an RN administered 5 mg of morphine sulfate instead of the prescribed 2 mg dose. The resident had severe cognitive impairment and diagnoses that included Alzheimer's disease, coronary artery disease, and dementia. The physician orders directed morphine sulfate concentrate oral solution 100 mg/5 mL to be given as 2 mg (0.1 mL) buccally every four hours for pain, with a separate PRN order for 5 mg (0.25 mL) buccally every hour as needed for breakthrough pain or shortness of breath. The EMAR showed the resident received the scheduled 2 mg dose at 4:00 p.m. and did not show a PRN 5 mg dose. During observation, RN-B withdrew 0.25 mL of morphine sulfate using the syringe provided with the medication and administered it buccally to the resident, then documented on the narcotic record book that 0.1 mL had been given. RN-B stated she gave 0.25 mL because the medication box label identified 0.25 mL, while RN-A stated the correct dose was 0.1 mL and acknowledged the error after RN-B confirmed the amount administered. The resident was assessed after the error and remained unchanged, with vital signs and condition stable. The DON stated the medication label had been followed instead of the EMAR, and the consultant pharmacist stated the resident could have experienced increased drowsiness from the error.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when it did not follow insulin pen preparation instructions for Resident #8. Resident #8 was admitted with multiple diagnoses including cerebral infarction (stroke), aphasia, and diabetes, and had a physician order for Humalog (Lispro) insulin pen-injector 100 units/ml to be injected subcutaneously at 5 units before meals for type 2 diabetes. During observation on 8/4/26, an LPN removed the Humalog insulin pen from the medication cart and dialed it to the ordered 5 units, but did not prime the pen with 2 units before administering the dose. The insulin was then given to Resident #8. When interviewed shortly afterward, the LPN stated she did not prime the insulin pen and was unaware of the need to do so before administering insulin. The DON stated insulin pens should be primed according to the manufacturer's instructions and had not been.
Significant medication error involving crushing a do-not-crush ER medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a Medication Aide crushed and administered medications that included Potassium Chloride ER, despite a physician order stating the medication was to be given by mouth twice daily and not crushed. The resident had diagnoses of chronic diastolic heart failure and dysphagia following a cerebral infarction, and the physician’s orders contained no instruction to crush medications. The facility policy stated medications should be administered as ordered and that medications with do-not-crush instructions, including slow release and enteric coated medications, should not be crushed. During observation, the Medication Aide confirmed they were going to crush all of the resident’s morning medications except Pantoprazole. The aide then placed Clopidogrel, Potassium Chloride ER, Sertraline, and Torsemide into a medication cup, crushed them, added pudding, and fed the mixture to the resident. The record review also identified Potassium Chloride as a high alert medication and cited guidance stating that enteric-coated or extended-release tablets or capsules should not be chewed or crushed.
Significant medication errors from delayed and missed ordered medications
Penalty
Summary
The facility failed to obtain physician-ordered medications in a timely manner, resulting in significant medication errors for two residents. One resident was admitted to the facility on 7/9/26 under hospice care with end-stage heart failure and had an order for Morphine Sulfate concentrate 10 mg sublingually every hour as needed for pain and/or air hunger. The resident did not receive Morphine on the day of admission, and the first documented dose was not given until 7/10/26 at 1:41 p.m., about 26 hours after admission. The MAR documented 26 potential missed PRN doses, and the resident’s family member and an LPN stated the medication was not available when needed and that the resident had signs of pain during that period. A second resident had orders for a Lidocaine external patch once daily for mild pain and Mirabegron ER 25 mg daily for urinary antispasmodic use. The MAR and nursing notes documented that the Lidocaine patch was not administered for multiple days because it was out of stock, with missed applications documented on 7/26, 7/27, 7/29, and 7/30, and 7/28 signed in error as given. The resident stated the missed patches prevented comfortable sleep. The same resident also missed Mirabegron doses on multiple days because the medication was on order from the pharmacy and not available, with documentation showing missed administration on 7/14, 7/15, 7/16, 7/17, 7/19, 7/20, and 7/21, and one date documented as given in error. The DON confirmed the Lidocaine order did not include a dose and acknowledged the resident missed several doses because the facility ran out of the patches. The DON also confirmed the Mirabegron was not supplied as expected and that the convenience box did not contain that medication. The resident and family member stated the missed medications affected pain control, sleep, and urinary urgency, and the DON stated the quantity of missed doses and unrelieved pain equated to significant medication errors.
Medication Order Transcription Error and Duplicate Pain Patch Application
Penalty
Summary
The facility failed to ensure a resident remained free from significant medication errors when admission medication orders were not accurately transcribed to the MAR. The resident was admitted with diagnoses including cerebral amyloid angiopathy, and the comprehensive assessment showed moderately impaired cognition and a need for assistance from one staff member with ADLs. The hospital discharge orders included a weekly buprenorphine transdermal patch, but the July 2026 MAR listed the medication as a weekly Suboxone transdermal patch instead. Staff later stated the wrong medication name was entered because Suboxone was believed to be the same medication as buprenorphine, and the admission body check was not completed to determine whether a transdermal patch was already present. The resident representative reported that facility staff applied a new pain patch without removing the old one, leaving two active patches on the resident for three days. Staff later confirmed one patch was on the right shoulder and another on the left shoulder, and the older patch was then removed. The DON stated the facility’s medication error process included staff interviews, physician notification, alert charting, and monitoring for high-alert medications, but also stated the incident was not investigated and no medication error report was completed. The DON further stated the admission process required a three-step verification of orders, and that process was not followed for this resident.
Missed Insulin Dose Due to Medication Unavailability
Penalty
Summary
A resident with type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and obesity had a physician order for Insulin Glargine Solostar 300 units/mL, 50 units subcutaneously once daily. On 3/20/26 at 11:19 AM, an RN documented that the insulin was not administered because the medication was unavailable. During interviews on 7/30/26, an LPN stated that medications should be reordered through the eMAR when five doses remain and that if a medication is completely out, staff must immediately notify the provider and pharmacy and use the emergency medication supply system. An RN confirmed that backup insulin was available in a lockbox in the third-floor refrigerator and that staff should not run out of insulin. The DON also confirmed the backup insulin location and the pharmacy restocking alert system, and stated there was no documentation in the progress notes or TAR explaining the omission; because she was not employed at the facility at the time, the exact reason for the unavailable medication and omitted dose remained unknown.
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