F0760

D

Multiple Medication Administration and Transcription Errors Affecting Several Residents

Lisbon, Iowa Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures to ensure residents were free from significant medication errors, including wrong-resident administration, incorrect timing and drug selection, and failures to correctly transcribe and implement hospital discharge orders and medication parameters. One resident with severe cognitive impairment and multiple serious diagnoses, including GI hemorrhage, heart failure, anemia, and orthostatic hypotension, was given another resident’s entire set of morning medications. These medications included multiple cardiac, anticoagulant, antidepressant, GI, diuretic, antihypertensive, and other agents that were not ordered for this resident. The error was identified and documented as a medication error, and it was noted that the morning medications had been administered by an LPN.

Another resident with osteoarthritis, anemia, HTN, and heart failure, and with intact cognition, had PRN opioid pain medication administered in violation of the ordered dosing interval and in place of a scheduled extended-release opioid. On one day, an LPN administered oxycodone 10 mg at 7:44 a.m. and again at 10:27 a.m., despite a prior dose at 5:41 a.m., even though the order specified administration every 6 hours PRN. Documentation showed that the 7:43–7:44 a.m. dose was ineffective with a follow-up pain score of 7, and an incident report identified that the PRN medication was given only 2.5 hours after the last dose. During the same shift, the same LPN documented holding the resident’s scheduled MS Contin 15 mg dose and instead administered another PRN oxycodone dose in place of the ordered scheduled morphine ER, contrary to the physician’s order.

A third resident with moderate cognitive impairment, heart failure, ESRD, Type 2 DM, and non-Alzheimer’s dementia experienced multiple medication transcription and administration errors related to hospital discharge instructions. Hospital documentation directed discontinuation of Jardiance, but the facility MAR showed the resident was on Farxiga, and there was no documentation that staff clarified this discrepancy between 1/5 and 1/15. A later hospital discharge summary ordered Farxiga to be stopped, yet the MAR showed Farxiga was administered for several days after the resident’s return before being discontinued. Hospital records also ordered Augmentin to be stopped and changed to Amoxil, but the MAR showed Augmentin was continued and only later discontinued, with Amoxil started afterward. Additionally, hospital orders directed that Lasix 60 mg be held until restarted by a provider due to low BP, but the MAR showed Lasix 60 mg was started and continued after the resident’s return.

Further, hospital documentation ordered initiation of Midodrine 5 mg TID for syncope, and a provider later added parameters to hold the medication if systolic BP was greater than 140. The MAR did not include these hold parameters, and Midodrine was administered three times daily over multiple days without documentation that BP was checked to ensure it was within the ordered parameters. Staff interviews confirmed that the Midodrine order on the MAR lacked hold parameters and that BP checks prior to administration were not documented. The DON stated that medication errors related to this resident’s Farxiga, Tramadol, and Amoxicillin were identified during a provider visit, and that the failure to implement Midodrine parameters was identified later. Facility policy required staff to read and follow transcribed physician orders on the EMAR, verify patient identity, and administer medications according to the ordered frequency and procedure, but the described events show these steps were not consistently followed for the residents involved.