F0760

E

Transcription Errors and Failure to Follow BP Parameters Lead to Significant Medication Errors

Norman, Oklahoma Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure accurate transcription and administration of admission medication orders for two residents, resulting in significant medication errors. For one resident admitted from the hospital with discharge orders for Eliquis, Famotidine, Culturelle, and Linezolid, the facility’s medication record shows these ordered medications were not administered for multiple days following admission. Instead, this resident received Duloxetine, Amlodipine, Atorvastatin, Levothyroxine, and Valsartan over the same period, which were not part of the hospital discharge medication list for that resident. The resident had diagnoses including atrial fibrillation and wound infection, and an admission assessment documented moderately impaired cognition with a BIMS score of 11.

The second resident’s hospital discharge medication list included Duloxetine, Amlodipine with specific blood pressure hold parameters, Atorvastatin, Levothyroxine, Valsartan, Celecoxib, and Prednisone. However, the medication record shows this resident did not receive these ordered medications for an extended period after admission. Instead, the resident received Eliquis, Famotidine, and Culturelle, which were not on this resident’s hospital discharge list but were ordered for the first resident. An admission assessment documented that this resident had diagnoses including hypertension and osteoporosis and had intact cognition with a BIMS score of 13.

Record review and interviews revealed that both residents were admitted on the same day and that the same nurse entered the medication orders for both residents and completed the drug regimen review. The facility’s root cause analysis documented that the medications intended for the second resident were entered on the first resident’s orders, and vice versa, and that the ADON and clinical team did not double-check the orders or recheck the drug regimen review. Additionally, the medication administration record for the first resident showed that Amlodipine was not held when the blood pressure reading was 105/69, despite physician-ordered parameters to hold the medication for systolic blood pressure below 110, diastolic below 60, or pulse below 60. Staff interviews confirmed that the orders were switched during entry, that another nurse did not double-check the orders, and that blood pressure medications with hold parameters should be held when readings are below those parameters.