F0759

D

Medication Error Rate Above 5% Due to Omitted Inhaler Dose and Improper Insulin Pen Preparation

Salisbury, North Carolina Survey Completed on 01-02-2026

Penalty

Fine: $20,385

Summary

The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 26 opportunities (7.6%) during a medication administration observation. For one resident with an order for Breo Ellipta 200-25 mcg per actuation, to be given as one puff by mouth once daily at 8:00 AM for shortness of breath and wheezing related to COPD and/or asthma, the medication was not administered during the observed morning medication pass. The medication aide reported that the Breo Ellipta inhaler was not available on the medication cart, and the unit manager stated that the prior inhaler had been identified as expired and removed from the cart, and that a replacement had been ordered but not yet delivered. The DON stated she would have expected the inhaler to have been ordered before it was out or expired so it would have been available as scheduled.

In a separate incident, surveyors observed a nurse preparing to administer Insulin Lispro via a prefilled insulin pen to another resident. The manufacturer’s Full Prescribing Information for the Insulin Lispro pen required priming with 2 units of insulin prior to each injection to ensure the pen was ready to dose and to remove air from the cartridge. The nurse attached a needle to the pen and dialed 15 units for administration but did not prime the pen before walking toward the resident’s room. When stopped outside the room and questioned, the nurse acknowledged she had not primed the pen and confirmed she was supposed to prime it before each injection. The DON confirmed that the Insulin Lispro pen needed to be primed with 2 units prior to each use and that she expected nursing staff to follow clinical guidelines for each medication administered.