F0759

D

Medication Administration Errors and Failure to Follow Physician and Manufacturer Instructions

Evanston, Illinois Survey Completed on 11-20-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure medications were administered as ordered and according to manufacturer instructions, resulting in a 16% medication error rate (4 errors out of 25 opportunities) during observation of medication administration. One resident, an older female with bilateral primary osteoarthritis, asthma, and essential hypertension, had multiple medication administration errors. Her physician orders included Advair Diskus inhaled every 12 hours, spironolactone 50 mg orally once daily, and Voltaren Gel 1% applied to both knees and feet twice daily with a 2 g dose. During a medication pass, the RN did not administer Advair Diskus as ordered but documented it as given in the MAR and instead showed the surveyor an Incruse Ellipta inhaler. Spironolactone was also not administered because it was reportedly not available, despite being ordered previously, and there was no indication at that time that the MAR was properly documented to reflect it was not given.

The same resident experienced errors with the administration of Voltaren Gel. The RN donned gloves and applied an unspecified “ample” or “desirable” amount of Voltaren Gel to each knee using his gloved hand, without using the dosing card supplied by the manufacturer to measure the ordered 2 g dose. The gel was not applied to the resident’s feet as required by the physician’s order, and the amount applied to the knees did not correspond to a measured 2 g dose. Manufacturer guidelines for Voltaren Gel specify that the proper amount must be measured using the dosing card, with the gel applied within the oblong area up to the appropriate gram line and then rubbed into the skin, but this process was not followed.

Another resident, an older male with a history of cerebral infarction and type 2 diabetes mellitus with hyperglycemia, also experienced a medication administration error involving insulin lispro. His physician orders included a standing order to inject 4 units SQ with meals for hyperglycemia and an additional sliding scale order (2 units for blood glucose 150–199 mg/dL, 3 units for 200–249 mg/dL, etc., with instructions to call the MD if blood glucose exceeded 350 mg/dL). During observation, an RN administered only 2 units of insulin lispro when the resident’s blood sugar was 167 mg/dL, stating that she followed only the sliding scale and believed the 4-unit order was merely a reminder and that the two orders “go together.” There was no documentation in the progress notes explaining why the 4-unit standing dose was not given, despite the care plan indicating that diabetes medications were to be administered as ordered by the physician and monitored for side effects and effectiveness.