Significant Medication Errors Involving Insulin and Antiepileptic Management
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically related to insulin administration for a resident with type 2 diabetes and antiepileptic medications for a resident with epilepsy. For the diabetic resident, the care plan identified a risk for blood sugar fluctuations and directed staff to administer medications as ordered, monitor blood glucose, follow hypoglycemia protocols, and report abnormal values to the physician. The resident’s insulin regimen was changed to include long-acting insulin at bedtime and scheduled short-acting insulin with meals plus a sliding scale. After this change, the resident experienced a first documented episode of severe hypoglycemia, during which an LPN found the resident non‑responsive with a critically low blood glucose and administered glucagon per protocol. The progress note for this event did not document that a provider was notified, and the medical director later confirmed he had not been made aware of this episode, nor had the insulin orders been reviewed or adjusted afterward. On a subsequent date, the same resident experienced another severe hypoglycemic episode. A CNA reported the resident felt hot, and when the LPN assessed the resident, she was diaphoretic and unresponsive with a blood glucose of 29. Multiple glucagon injections and oral glucose were administered with assistance from other nurses and a nurse practitioner, and the resident was ultimately sent to the hospital. Hospital records documented that the resident had been receiving 10 units of long‑acting insulin at night and 2 units of insulin with meals, and noted that hypoglycemia could be due to an insulin dosing error or accurate dosing in a patient not eating adequately. Review of the resident’s orders and MAR showed that the short‑acting insulin lispro was ordered as 7 units with meals plus a sliding scale, and that on the day of the second hypoglycemic event, the LPN administered 7 units of lispro at 10:32 a.m. for a blood glucose of 140 and then again at 1:05 p.m., giving 7 units plus 2 units per sliding scale for a blood glucose of 177. The LPN later acknowledged she was behind on medications, gave the morning and lunch insulin doses 2.5 hours apart, did not know whether the resident had eaten breakfast or lunch or how much was consumed, and did not realize the doses were so close together. The DON confirmed the insulin doses were given late and that nurses were expected to administer insulin with meals, check blood glucose before eating, and assess intake, while the medical director, PA, and pharmacist all stated they would be concerned about lispro being given 2.5 hours apart without knowledge of food intake. The second resident had a diagnosis of epilepsy and a care plan goal to remain free from injury related to seizure activity, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. MAR review showed that this resident missed multiple doses of Keppra and valproic acid over several days, including missed morning doses of Keppra and multiple missed doses of valproic acid on consecutive days. Progress notes documented that the resident refused morning medications on one day, that the nurse reapproached and the resident took only part of the medications, and that the resident’s family member expressed concern about lethargy, abnormal responsiveness, and the possibility of seizure, requesting hospital evaluation. The resident was sent to the hospital and returned with an increased Keppra dose, but subsequent notes indicated ongoing lethargy, refusal of meals, and refusal of medications. The resident later had seizure activity at the facility, and days afterward, staff documented that the resident had been unable to swallow food and medications for several days and that valproic acid was not given for this reason, leading to a provider notification and transfer to the emergency department. Hospital records for this resident described a history of TBI, epilepsy, and nonverbal status, with presentation for failure to thrive and significant dysphagia over 24–48 hours, during which the resident was unable to take medicines or oral intake. The family reported being told that oral antiepileptic medications drooled out of the resident’s mouth and could not be swallowed, and that the last seizure a few days prior was believed to be due to inability to take oral medications. The hospitalization summary noted status epilepticus and an acute ischemic infarction, and the attending physician stated that due to dysphagia the resident frequently missed antiepileptic doses, making breakthrough seizures unsurprising. Interviews with facility staff revealed that the LPN caring for the resident on one of the key days could not recall whether the provider was notified about missed Keppra and valproic acid doses, and the unit manager acknowledged she did not further investigate family concerns and confirmed multiple missed doses without documentation of provider notification. Another LPN reported being told by a CNA that the resident had been having swallowing issues and missing medications for days before she assessed the resident, notified the provider, and arranged hospital transfer. The DON and PA both stated that nurses were expected to notify providers whenever medications were missed or there was a change in condition, and review of records showed no documentation that providers were notified of the repeated missed antiepileptic doses due to dysphagia. Facility policies on medication administration required medications to be given as prescribed, within one hour before or after scheduled times, with before/after meal orders followed as written, and required explanatory notes and notification of the DON and physician when two doses of a medication were refused or withheld. The change in condition policy required that sudden or serious changes in condition be communicated to the physician with a request for prompt evaluation, and that all nursing actions be documented in progress notes. In both residents’ cases, the documented findings show that medications were not administered in accordance with physician orders and facility policy, that critical changes in condition and missed doses were not consistently communicated to providers, and that documentation of provider notification was lacking despite repeated episodes of hypoglycemia and missed antiepileptic doses associated with dysphagia and seizure activity.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Significant morphine dose error: An RN administered 0.25 mL (5 mg) of morphine sulfate buccally instead of the ordered 0.1 mL (2 mg) dose to a resident with severe cognitive impairment, Alzheimer’s disease, CAD, and dementia. The RN said she followed the medication box label, while the unit manager confirmed the correct dose was on the EMAR. The resident was assessed afterward and remained unchanged.
An LPN administered Humalog insulin to a resident with stroke, aphasia, and diabetes without priming the insulin pen as required by manufacturer instructions. The LPN dialed the ordered 5-unit dose but did not prime the pen with 2 units before injection, and later stated she was unaware of the need to prime it. The DON confirmed insulin pens should be primed according to the manufacturer's instructions.
A resident with CHF and dysphagia had a medication error when an MA crushed and administered multiple morning meds, including Potassium Chloride ER, despite a provider order that it not be crushed. The facility policy required meds to be given as ordered and prohibited crushing do-not-crush, slow-release, and enteric-coated meds; the record also identified potassium chloride as a high-alert medication.
Two residents experienced significant medication errors when ordered meds were not available or not administered as prescribed. One resident on hospice went more than 24 hours after admission without ordered Morphine for pain and air hunger, while another resident missed multiple doses of a Lidocaine patch and Mirabegron because the meds were out of stock or not obtained from the pharmacy, with the DON confirming the missed doses and unrelieved pain were significant.
A resident with moderately impaired cognition and cerebral amyloid angiopathy had a weekly buprenorphine patch order inaccurately transcribed as Suboxone on the MAR. Staff also applied a new pain patch without removing the old one, leaving two active patches on the resident for several days. The DON stated the admission verification process was not followed and the incident was not investigated.
A resident with DM2 and multiple chronic conditions had an order for daily insulin glargine, but an RN documented that the dose was not given because the medication was unavailable. An LPN stated staff should reorder meds when five doses remain and, if out, notify the provider and pharmacy and use the emergency medication supply system; an RN and the DON confirmed backup insulin was available in a lockbox, and the DON noted there was no documentation explaining the omission.
Significant morphine dose error
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when an RN administered 5 mg of morphine sulfate instead of the prescribed 2 mg dose. The resident had severe cognitive impairment and diagnoses that included Alzheimer's disease, coronary artery disease, and dementia. The physician orders directed morphine sulfate concentrate oral solution 100 mg/5 mL to be given as 2 mg (0.1 mL) buccally every four hours for pain, with a separate PRN order for 5 mg (0.25 mL) buccally every hour as needed for breakthrough pain or shortness of breath. The EMAR showed the resident received the scheduled 2 mg dose at 4:00 p.m. and did not show a PRN 5 mg dose. During observation, RN-B withdrew 0.25 mL of morphine sulfate using the syringe provided with the medication and administered it buccally to the resident, then documented on the narcotic record book that 0.1 mL had been given. RN-B stated she gave 0.25 mL because the medication box label identified 0.25 mL, while RN-A stated the correct dose was 0.1 mL and acknowledged the error after RN-B confirmed the amount administered. The resident was assessed after the error and remained unchanged, with vital signs and condition stable. The DON stated the medication label had been followed instead of the EMAR, and the consultant pharmacist stated the resident could have experienced increased drowsiness from the error.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when it did not follow insulin pen preparation instructions for Resident #8. Resident #8 was admitted with multiple diagnoses including cerebral infarction (stroke), aphasia, and diabetes, and had a physician order for Humalog (Lispro) insulin pen-injector 100 units/ml to be injected subcutaneously at 5 units before meals for type 2 diabetes. During observation on 8/4/26, an LPN removed the Humalog insulin pen from the medication cart and dialed it to the ordered 5 units, but did not prime the pen with 2 units before administering the dose. The insulin was then given to Resident #8. When interviewed shortly afterward, the LPN stated she did not prime the insulin pen and was unaware of the need to do so before administering insulin. The DON stated insulin pens should be primed according to the manufacturer's instructions and had not been.
Significant medication error involving crushing a do-not-crush ER medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a Medication Aide crushed and administered medications that included Potassium Chloride ER, despite a physician order stating the medication was to be given by mouth twice daily and not crushed. The resident had diagnoses of chronic diastolic heart failure and dysphagia following a cerebral infarction, and the physician’s orders contained no instruction to crush medications. The facility policy stated medications should be administered as ordered and that medications with do-not-crush instructions, including slow release and enteric coated medications, should not be crushed. During observation, the Medication Aide confirmed they were going to crush all of the resident’s morning medications except Pantoprazole. The aide then placed Clopidogrel, Potassium Chloride ER, Sertraline, and Torsemide into a medication cup, crushed them, added pudding, and fed the mixture to the resident. The record review also identified Potassium Chloride as a high alert medication and cited guidance stating that enteric-coated or extended-release tablets or capsules should not be chewed or crushed.
Significant medication errors from delayed and missed ordered medications
Penalty
Summary
The facility failed to obtain physician-ordered medications in a timely manner, resulting in significant medication errors for two residents. One resident was admitted to the facility on 7/9/26 under hospice care with end-stage heart failure and had an order for Morphine Sulfate concentrate 10 mg sublingually every hour as needed for pain and/or air hunger. The resident did not receive Morphine on the day of admission, and the first documented dose was not given until 7/10/26 at 1:41 p.m., about 26 hours after admission. The MAR documented 26 potential missed PRN doses, and the resident’s family member and an LPN stated the medication was not available when needed and that the resident had signs of pain during that period. A second resident had orders for a Lidocaine external patch once daily for mild pain and Mirabegron ER 25 mg daily for urinary antispasmodic use. The MAR and nursing notes documented that the Lidocaine patch was not administered for multiple days because it was out of stock, with missed applications documented on 7/26, 7/27, 7/29, and 7/30, and 7/28 signed in error as given. The resident stated the missed patches prevented comfortable sleep. The same resident also missed Mirabegron doses on multiple days because the medication was on order from the pharmacy and not available, with documentation showing missed administration on 7/14, 7/15, 7/16, 7/17, 7/19, 7/20, and 7/21, and one date documented as given in error. The DON confirmed the Lidocaine order did not include a dose and acknowledged the resident missed several doses because the facility ran out of the patches. The DON also confirmed the Mirabegron was not supplied as expected and that the convenience box did not contain that medication. The resident and family member stated the missed medications affected pain control, sleep, and urinary urgency, and the DON stated the quantity of missed doses and unrelieved pain equated to significant medication errors.
Medication Order Transcription Error and Duplicate Pain Patch Application
Penalty
Summary
The facility failed to ensure a resident remained free from significant medication errors when admission medication orders were not accurately transcribed to the MAR. The resident was admitted with diagnoses including cerebral amyloid angiopathy, and the comprehensive assessment showed moderately impaired cognition and a need for assistance from one staff member with ADLs. The hospital discharge orders included a weekly buprenorphine transdermal patch, but the July 2026 MAR listed the medication as a weekly Suboxone transdermal patch instead. Staff later stated the wrong medication name was entered because Suboxone was believed to be the same medication as buprenorphine, and the admission body check was not completed to determine whether a transdermal patch was already present. The resident representative reported that facility staff applied a new pain patch without removing the old one, leaving two active patches on the resident for three days. Staff later confirmed one patch was on the right shoulder and another on the left shoulder, and the older patch was then removed. The DON stated the facility’s medication error process included staff interviews, physician notification, alert charting, and monitoring for high-alert medications, but also stated the incident was not investigated and no medication error report was completed. The DON further stated the admission process required a three-step verification of orders, and that process was not followed for this resident.
Missed Insulin Dose Due to Medication Unavailability
Penalty
Summary
A resident with type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and obesity had a physician order for Insulin Glargine Solostar 300 units/mL, 50 units subcutaneously once daily. On 3/20/26 at 11:19 AM, an RN documented that the insulin was not administered because the medication was unavailable. During interviews on 7/30/26, an LPN stated that medications should be reordered through the eMAR when five doses remain and that if a medication is completely out, staff must immediately notify the provider and pharmacy and use the emergency medication supply system. An RN confirmed that backup insulin was available in a lockbox in the third-floor refrigerator and that staff should not run out of insulin. The DON also confirmed the backup insulin location and the pharmacy restocking alert system, and stated there was no documentation in the progress notes or TAR explaining the omission; because she was not employed at the facility at the time, the exact reason for the unavailable medication and omitted dose remained unknown.
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