F0760

G

Significant Medication Errors from Incorrect Order Transcription and Failure to Follow Prescriber Directions

Springfield, Missouri Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures to ensure residents were free from significant medication errors, primarily related to inaccurate transcription and implementation of physician and hospital discharge orders. For one resident with a recent heart attack, CHF, COPD, diabetes, and severe cognitive impairment, the hospital discharge order for digoxin was 125 mcg by mouth once daily. Upon readmission, an LPN entered the order into the electronic record as 125 mcg four times daily, which did not match the hospital order. The physician order sheet and MAR reflected this incorrect frequency, and the system generated notes indicating the dose and frequency were outside usual recommended ranges, but there was no documented follow-up with the physician. The resident’s MAR showed missed doses initially due to medication unavailability without documented physician notification, followed by consistent administration of digoxin four times daily over several days.

During this period, secure messages documented that nursing staff reported the resident was sleeping a lot, had low BP, poor appetite, and low energy, and that labs were drawn, but there was no immediate correction of the digoxin order. The resident’s digoxin level later returned critically high (greater than 5 ng/mL), and staff confirmed that the admission nurse had entered the order incorrectly as four times daily instead of once daily. The resident exhibited lethargy, confusion, nausea, vomiting, poor intake, hypotension, weak and thready pulses, and low heart rates, with multiple vital sign entries showing bradycardia and hypotension. The resident was ultimately sent to the hospital, where documentation indicated admission for altered mental status, hypotension, and digoxin toxicity with a digoxin level of 6.6 ng/mL, and treatment with Digibind and vasopressors in the ICU. Interviews with staff revealed that the LPN who entered the order did not realize it did not match the hospital discharge order, did not notify the physician of the resident’s return, and assumed the physician would review the orders, while other staff acknowledged that digoxin is typically given once daily and that the wrong dose was discovered only after the critical lab result.

Another resident with paraplegia, lumbar spina bifida, and a history of thrombosis and embolism had a hospital discharge order for warfarin 1 mg tablets, with instructions to administer 3 tablets on Mondays and 2 tablets on all other days, and to hold the dose on the day of discharge pending a PT/INR recheck. When this resident was readmitted, the physician order sheet instead showed warfarin 1 mg, 3 tablets by mouth once daily starting the following day, without the variable dosing schedule specified by the hospital. The MAR reflected a daily 3 mg dose at 9:00 A.M., and staff documented administration of this dose every day over the remainder of the month. Although the care plan and nurse MAR included monitoring for anticoagulant side effects and staff documented monitoring twice daily, the warfarin order as transcribed and administered did not match the hospital discharge instructions, resulting in the resident receiving a higher total weekly dose than ordered by the hospital and not following the specified dosing pattern tied to PT/INR monitoring.

The report also notes additional deficiencies for other residents, including failure to follow physician recommendations for changes to insulin dosing and blood sugar checks for one resident, resulting in administration of less insulin and fewer blood glucose checks than recommended, and failure to administer psychotropic medications as ordered for another resident. The facility’s own policies required that admission/readmission orders be obtained and verified on the day of admission, that medications be administered exactly as prescribed, that MAR entries be compared with prescriber orders, and that unusual doses or directions be clarified with the prescriber or pharmacy and documented. Interviews with the ADON indicated uncertainty about whether nurses communicated admission/readmission orders to the physician or performed any second check on orders for accuracy. Collectively, these actions and inactions led to significant medication errors involving digoxin, warfarin, insulin, and psychotropic medications for multiple residents.