Failure of Pharmacy Services and Consultant Pharmacist to Detect Incorrect IV Antibiotic Stop Date
Summary
The deficiency involves a failure of the facility’s pharmaceutical services, including both the contracted pharmacy provider and the consultant pharmacist, to identify a transcription error in an IV antibiotic order, resulting in an incorrect stop date and an extended omission of ordered doses. A resident was admitted with diagnoses including UTI, urinary retention, and Enterococcus faecalis bacteremia, and had hospital infectious disease orders for Ampicillin 2 g IV every 4 hours to continue through a specified date in January. The hospital discharge summary and infectious disease note documented Ampicillin 2 g IV every 4 hours with a stop date of January 13. The facility faxed the admission orders to the pharmacy provider, and the order was entered into the facility’s electronic system (PCC) on the day of admission as Ampicillin Sodium Solution 2 g IV every 4 hours, but with an incorrect stop date of December 13 instead of January 13. The order was confirmed in the system later that same day. According to facility policy, the consultant pharmacist is responsible for providing consultation on all aspects of pharmacy services, including helping the facility develop processes for receiving and transcribing medication orders, and for performing a Medication Regimen Review (MRR) for every resident upon admission and at least monthly. The MRR is to include a thorough review of the medical record to prevent, identify, report, and resolve medication-related problems and errors, including omissions of ordered medications and documentation-related errors. The pharmaceutical services agreement with the pharmacy provider also requires that a licensed pharmacist review each resident’s drug regimen, including the medical chart, and report any irregularities to the attending physician, medical director, and DON. The agreement further states that the pharmacy will use an electronic system (PCC) to manage orders and MARs and that the pharmacy’s medical records department is responsible for ensuring that faxed orders match what is entered into PCC. Despite these requirements, multiple review processes failed to detect the incorrect stop date. The pharmacy provider received the faxed admission orders on the day of admission, which correctly showed Ampicillin 2 g IV every 4 hours with a stop date of January 13, but the facility-entered order in PCC reflected a stop date of December 13. A pharmacist from the pharmacy provider performed a Drug Regimen Review on the day of admission and documented that the medications were reviewed with no recommendations. The consultant pharmacist completed an admission Pharmacy Drug Regimen Review three days later and also documented no recommendations or irregularities. The consultant pharmacist later stated that she reviews new admission medications to ensure physician orders match what is entered in PCC and that stop dates are part of this review, and acknowledged she should have identified an incorrect stop date. The pharmacy provider’s Director of Operations confirmed that the medical records department’s verification, completed three days after admission, should have identified the discrepancy between the faxed order’s January stop date and the December stop date entered in PCC but did not. As a result, the MAR shows the resident received Ampicillin IV every four hours from the evening of admission through December 13, when the medication stopped per the incorrect stop date, and the resident then missed 59 doses between December 13 and December 24, when the error was finally identified and the medication was resumed. Interviews further clarified the sequence of events and the roles of involved staff. The DON stated that the admissions nurse entered the Ampicillin order with the incorrect December stop date, causing the medication to stop in error on that date. The DON confirmed that the error was not identified until December 24, at which time an order was obtained to resume the medication, and that the resident missed doses every four hours during the gap period. The Medication Occurrence Report documented the error as an omitted dosage due to an admission order error and chart check error, specifying that the wrong stop date was entered on admission and that infectious disease orders present in the record had the correct January stop date. The pharmacy provider’s Director of Operations confirmed that the faxed order to the pharmacy showed the correct January stop date, that the facility had entered a December stop date into PCC, and that the pharmacy’s medical records verification process should have detected and reported this discrepancy but did not. These combined failures by the facility’s pharmacy services and consultant pharmacist to identify and correct the transcription discrepancy led to the prolonged interruption of the resident’s ordered IV antibiotic therapy.
Penalty
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Insulin Pen Not Primed Before Administration: An LVN administered Lantus to a resident with diabetes without priming the insulin pen first. The resident had orders for Lantus 30 units BID, and the LVN stated he was not familiar with priming the pen. The DON stated the pen should be primed before use to ensure the resident receives the appropriate dose.
A resident with restlessness, agitation, pain, palliative care, and a frontotemporal neurocognitive disorder had mismatched Ativan directions across the physician order, narcotic book, EMAR, and bubble pack card. The LPN, pharmacist, and DON all confirmed the entries should have matched, and the pharmacy card lacked notation for the different tablet strength listed in the EMAR.
Incorrect Sertraline Dose Administered: A resident with major depressive disorder and intact cognition was ordered sertraline 150 mg daily, but an MA administered only 100 mg after noticing the order called for 1.5 tablets and not pausing to clarify the discrepancy. The med label also showed 1 tablet, and the DON/VPCS stated staff should check orders against the MAR before administration; the facility policy required verifying the label and dose.
Expired influenza vaccines were found in the refrigerator of The Arbors medication room during an observation. Nurses stated they were responsible for checking medication rooms for expired meds, but the expired vaccines remained in storage despite staff being told to remove them before expiration. The DON, ADON, and Administrator each identified staff responsibility for checking medication rooms, and the facility policy stated multi-dose vials are discarded according to the manufacturer’s expiration date.
Controlled medications awaiting disposal were found stored in a locked cabinet in the med room, including Pregabalin, Lorazepam, Tramadol, Fentanyl patches, and Morphine. An LVN said the meds had been there for about a week, were not counted after placement, and one Morphine count sheet was missing from the cabinet. The DON said discontinued narcotics were supposed to be brought to her immediately for reconciliation and locked storage, but she had forgotten to retrieve them.
A resident with DM, ESRD, bipolar disorder, and autism had an order for Ritalin 20 mg BID for ADHD, but the medication was not administered for five days and nine scheduled doses were missed. Nursing notes repeatedly documented the drug as pending delivery, pending approval, or pending script, and the MAR showed each dose signed off with Code 9. The physician was not aware the resident had not received the medication, and the DON stated the delay occurred because the facility had to fax the hard copy prescription to the pharmacy.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when LVN B administered Lantus insulin to Resident #97 without priming the insulin pen first. Resident #97 was a cognitively intact male with diagnoses that included diabetes, peripheral vascular disease, acquired absence of left toes, and acquired absence of the right leg below the knee. His orders included Lantus 100 unit/mL insulin, 30 units subcutaneously twice daily, and his care plan identified diabetes with interventions for administering medications as ordered. During observation, LVN B obtained the insulin pen from the medication cart, inserted a needle into the rubber seal without cleaning it first, did not prime the pen, dialed the dose to 30 units, and injected the resident. When interviewed, LVN B stated he was not familiar with priming an insulin pen and did not fully know the technology behind priming it, despite having skills training within the year that included insulin use. The DON stated that an insulin pen should be primed before administration and checked for air bubbles because priming ensures the resident receives the appropriate dose. The Lantus package insert also stated to perform the safety test before each injection to ensure an accurate dose.
Medication Transcription Mismatch for Narcotic Order
Penalty
Summary
The facility failed to transcribe medication orders according to standards of practice for medication management for one resident with restlessness and agitation, pain, palliative care, and a frontotemporal neurocognitive disorder. The resident’s physician order for Ativan 0.5 mg solutabs directed that 0.25 mg be given by mouth every 4 hours as needed for restlessness, but the corresponding narcotic book page listed Ativan 5 mg every 4 hours as needed, while the EMAR listed 0.5 mg solutabs with directions to give 0.25 mg by mouth every 4 hours as needed. The bubble pack card for Ativan listed lorazepam 0.25 mg solutab with directions to dissolve 1 tablet by mouth three times a day and dissolve 1 tablet by mouth every 4 hours as needed, and the pharmacy card did not include a sticker or other notation to indicate the different tablet strength listed in the EMAR and not on the card. During observation of the medication cart, the narcotic drawer contained the resident’s Ativan 0.25 mg by mouth card, while the narcotic book page listed Ativan 5 mg every 4 hours as needed and the EMAR listed 0.5 mg solutabs with 0.25 mg by mouth every 4 hours as needed. The LPN confirmed the transcribed locations for the same order did not match and should have. The LPN described the facility process for receiving and transcribing new narcotics, including verification by two nurses and use of the index and narcotic book during counts. The pharmacist confirmed all three areas for the order, narcotic book, and card should match and stated that if there was a change in dose or tablet strength, the card should have had a sticker or other notation, but it did not. The DON stated staff were expected to enter orders received from the pharmacy, have two nurses count and verify the medications, write the correct directions for use in the narcotic book, and compare all areas during narcotic count and medication administration. A policy for medication transcription was requested but not provided.
Incorrect Sertraline Dose Administered
Penalty
Summary
Pharmaceutical services failed to meet the needs of Resident #16 when the facility did not ensure the ordered dose of sertraline was administered. Resident #16 was a [AGE]-year-old female admitted on [DATE] with diagnoses including major depressive disorder, recurrent, unspecified. Her quarterly MDS reflected a BIMS score of 13, indicating intact cognition, and documented that she was prescribed an antidepressant medication. The physician’s order dated 6/25/2026 directed sertraline HCl 100 mg tablets, 1.5 tablets by mouth in the morning for depression, with documentation in the progress notes that the Zoloft dose had been increased from 100 mg daily to 150 mg daily for improved symptom control. During observation on 7/09/2026 at 7:53 AM, MA A prepared medications for Resident #16 and the sertraline package label identified the medication as sertraline HCl 100 mg with instructions to give 1 tablet by mouth in the morning for depression. MA A administered 1 tablet of sertraline 100 mg instead of the ordered 1.5 tablets. In interview immediately afterward, MA A stated she noticed the order said one and a half tablets but was nervous and did not want to pause medication administration to clarify the order before giving the medication. She also stated she was not informed of a change to the sertraline dosage and should notify the nurse if she noticed a discrepancy between the medication order and the label. The VPCS stated staff should check all orders before administering medications and that the potential harm was medication error. The facility policy required staff to check the medication label against the MAR and re-check the dose to confirm the proper dose.
Expired Influenza Vaccines Left in Medication Room Refrigerator
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 2 medication storage rooms reviewed, The Arbors. During an observation on 7/7/2026 at 10:41 am, the refrigerator in the medication room contained 3 boxes of influenza vaccine for the 2025-2026 season, lot #AX615A, that had expired on 6/30/2026. LVN A was present in the medication room and stated nurses were responsible for checking medication rooms daily, but she was not aware the vaccines were expired and said she would discard them. During interviews, RN B stated night shift nurses were responsible for checking medication rooms for expired medications and said she was not aware the expired influenza vaccines were in The Arbors medication room. The ADON stated nurses were responsible for checking medication rooms at night and said she had instructed staff before the end of June 2026 to remove the vaccines, but they were not removed. The DON stated nurses were responsible for daily night shift checks for expired medications and said staff had been told to remove the flu vaccines before they expired, but they did not. The Administrator stated the pharmacist, DON, and ADON were responsible for checking medication rooms and said they should be checked weekly for expired medications. Record review of the facility policy titled Medication Labeling and Storage, revised June 2026, stated that multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.
Controlled Medications Left Unreconciled in Medication Room
Penalty
Summary
The facility failed to establish a system for the receipt and disposition of controlled drugs in sufficient detail to allow accurate reconciliation and an account of all controlled medications. During an observation in the medication room, controlled medications awaiting disposal were found stored underneath a counter in a locked cabinet that all nurses had a key to, including Pregabalin 25 mg tablets, Lorazepam 0.5 mg tablets, Tramadol 50 mg tablets, Fentanyl 50 mcg patches, and Morphine 100 mg/5 ml. LVN B stated the controlled medications had been under the cabinet for about a week and that discontinued narcotics were supposed to be taken to the DON immediately to be logged and locked in the DON's office. She also stated no one counted the medications once they were placed in the medication room and that the cabinet was missing a count sheet for one Morphine bottle, which she found folded in the narcotic count sheet book. The DON stated her locked area for discontinued narcotic medications was in the ADON's office and that she was the only one with keys. She said she intended to retrieve the discontinued narcotic medications on Monday but forgot, and that her expectation was for nurses to bring discontinued medications to her immediately after removal from the medication cart so she could reconcile them and lock them in her double-locked area. The DON also stated she normally checked with nurses on Monday, Wednesday, and Friday mornings to ensure narcotic medications were reconciled properly. The Administrator stated discontinued narcotic medications should be taken to the DON immediately and that the DON was responsible for ensuring no controlled medications were stored in the medication room.
Delay in Obtaining Ordered Ritalin
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when it did not ensure timely acquisition and administration of an ordered CNS stimulant medication for one resident. The resident was admitted with diagnoses including Type 2 diabetes, end stage renal disease, bipolar disorder, and autistic disorder. A physician order for Ritalin 20 mg by mouth twice daily for ADHD was entered with a start date of 06/26/2026, but the medication was not administered through 06/30/2026, resulting in a five-day delay and nine consecutive missed scheduled doses. The June 2026 MAR showed each scheduled dose of Ritalin was signed off with Code 9, indicating other, see progress notes, and no doses were given during the review period. Nursing documentation repeatedly noted the medication was pending delivery, pending approval, or pending script, and one note stated the resident was out for dialysis. The resident's initial MDS assessment was still in progress and the initial care plan assessment had not been completed. During interviews, the physician stated he was not aware the resident had not received Ritalin because it was pending from pharmacy and said the effect would be that the resident would not be able to concentrate. An LVN stated that if a medication was unavailable, the physician should be called for a prescription and the DON notified if doses were missed. The ADON stated staff should check the automated medication dispensing system, obtain a retrieval code from the pharmacy, and notify the physician immediately if the medication was unavailable, and acknowledged there had been miscommunication with the pharmacy. The DON stated the nurses were responsible for verifying admission orders and that the five-day delay occurred because the facility had to fax the hard copy prescription to the pharmacy.
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