F0759

E

Medication Pass Errors Resulting in 19% Medication Error Rate

Southfield, Michigan Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 25 opportunities (19%) during a medication pass involving three residents. For one resident (R57), a nurse prepared and administered a set of morning medications, including magnesium oxide 400 mg, folic acid 400 mcg, and gabapentin 100 mg. The nurse crushed all medications, including the gabapentin capsule, and mixed them with applesauce before administration, then confirmed all medications due had been given. Subsequent reconciliation with the physician’s orders showed that the ordered dose of magnesium oxide was 440 mg, and the ordered dose of folic acid was 1 mg, not 400 mcg as administered. It was also discovered that an ordered dose of famotidine 20 mg for this resident was not prepared or administered at that time.

For another resident (R92), a nurse prepared and administered medications that included a sennosides 8.6 mg tablet. When the administered medications were reconciled with the physician’s orders, it was found that the resident did not have an order for sennosides alone, but instead had an order for Senna-S, a combination product containing sennosides 8.6 mg and docusate sodium 50 mg. During an interview, the DON stated that gabapentin capsules should not be crushed but opened and the contents emptied, and that nurses are expected to follow the rights of medication administration (right resident, medication, dose, route, time). The facility’s medication administration policy, reviewed in 2/2026, requires safe and accurate preparation and administration of medications according to physician orders and professional standards, adherence to the rights of medication administration, and not crushing medications when contraindicated or without a physician’s order.