Medication Administration and Documentation Errors Resulting in Elevated Error Rate
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 6 errors out of 31 medication administration opportunities, resulting in a 19.35% error rate. For one resident, record review showed active orders for Calmoseptine ointment to be applied to the bilateral buttocks four times daily for barrier protection and a daily multivitamin tablet related to a sacral pressure ulcer. During a medication pass observation, the medication aide documented both the Calmoseptine and the multivitamin as “given,” but did not remove either medication from the cart or administer them at that time. In an interview during the observation, the medication aide confirmed charting the Calmoseptine as given but stated it would not actually be administered until the resident left the dining room. For another resident, record review showed active orders for Flonase nasal spray for nasal congestion and drainage, Ipratropium Bromide nasal solution for sinusitis, Nystatin powder ordered both as needed and scheduled for application under the breasts for itching, and Potassium Chloride oral tablets as a nutritional supplement. The facility’s documentation policy required accurate charting, proper correction of errors, and detailed documentation of treatment refusals, including resident response, reasons for refusal, and physician notification. Observation of a medication pass revealed the medication aide charted all of these medications as “given,” but only removed oral tablets from the cart and mixed them into pudding. When the resident refused the Potassium Chloride tablet, the aide removed the pill from the pudding and discarded it in the resident’s trash without attempting to discuss the need for the medication or notifying nursing or providers of the refusal. The resident later confirmed that the Nystatin powder, Flonase nasal spray, and Ipratropium Bromide nasal solution were not offered and described using the nasal spray only after blowing the nose and the Nystatin powder after showering or when excessively sweating.
Penalty
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Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
Surveyors observed that an LPN committed three medication errors during 36 administration opportunities, resulting in a medication error rate above 5%. A resident with an order for crushed medications received Ingreeza prepared by softening the capsule in pudding instead of sprinkling the capsule contents as ordered. The same resident did not receive ordered Flonase nasal spray and olopatadine eye drops because the medications were not available. The ADON confirmed the improper Ingreeza administration as a significant medication error, and the NHA acknowledged that the facility exceeded the allowable medication error rate.
Surveyors identified that the facility failed to keep its medication error rate below 5%, finding three errors among 26 opportunities (11.45%). One resident with constipation did not receive a prescribed daily dose of polyethylene glycol when an RN mixed the laxative, placed it on the over-bed table, administered other meds, and left the room without giving it. Another resident with constipation received only part of a polyethylene glycol dose when an RN gave a single drink of the dissolved laxative, then left the remaining medicated solution at the bedside and exited the room. A third resident with GERD, ordered calcium carbonate 600 mg each morning, was administered 1000 mg when an RN used tablets labeled 1000 mg and later acknowledged not realizing a 600 mg strength existed.
Surveyors observed two medication administration errors that caused the facility’s medication error rate to exceed 5%. In one case, an LPN administered insulin using a pen device to a resident with diabetes without priming the pen as required by the manufacturer’s instructions. In another case, an LPN measured a resident’s ordered 17 g dose of MiraLAX by filling the product cap only partway instead of to the top rim as specified on the container, then administered the inaccurately measured dose. These actions resulted in a calculated medication error rate of 7.14% during the survey.
Surveyors found that the facility’s medication error rate exceeded 5% after observing an RN administer a morning medication pass in which Duloxetine 60 mg, ordered to be given at bedtime for depression, was instead given in the morning, and Famotidine 20 mg, ordered once daily in the morning for GERD, was not observed being administered but was signed out as given on the MAR. These administration and documentation errors contributed to a calculated medication error rate of 6.45%.
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Medication Error Rate Exceeded Due to Omitted and Improperly Administered Medications
Penalty
Summary
Surveyors determined that the facility failed to maintain a medication error rate below 5%, identifying three errors out of 36 medication administration opportunities, resulting in an 8.33% error rate. During a medication pass observation on 4/1/26 at 8:56 a.m., an LPN prepared a 40 mg Ingreeza capsule for a resident with an order for medications to be crushed, by softening the capsule in pudding rather than sprinkling the capsule contents in pudding as ordered. The LPN later confirmed that she did not prepare and administer the Ingreeza in accordance with the ordered method. In the same observation period, the LPN failed to administer the resident’s ordered 50 mcg/actuation fluticasone propionate (Flonase) nasal spray and 1 mg/mL olopatadine ophthalmic solution because these medications were not available. The LPN acknowledged that these medications were not given due to unavailability. The Assistant DON confirmed that the Ingreeza administration constituted a significant medication error, and the Nursing Home Administrator confirmed that the facility did not meet the requirement to remain free of a medication error rate of 5% or greater, based on the three identified errors out of 36 opportunities.
Medication Administration Errors Exceeding Acceptable Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 26 opportunities (11.45%) during medication administration observations. For a resident admitted with constipation, a physician’s order dated 01/06/26 directed administration of 17 grams of polyethylene glycol powder by mouth once daily. On 03/24/26 at 10:00 AM, a nurse mixed the polyethylene glycol in water, brought it to the bedside, placed it on the over-bed table, and then administered other medications and a flavored liquid used to swallow pills. The nurse left the room without giving the polyethylene glycol. When questioned at 10:30 AM, the nurse acknowledged leaving the medication on the table and stated she forgot to administer it because she was nervous; the mixed medication remained on the table in the resident’s room. Another resident with constipation had a physician’s order dated 12/14/23 for polyethylene glycol, one packet by mouth every other day, dissolved in 4–6 oz of fluid. On 03/24/26 at 9:20 AM, a nurse prepared this resident’s medications, including dissolving the polyethylene glycol in water, administered the crushed medications, gave the resident one drink of the polyethylene glycol mixture, then placed the remaining mixture on the over-bed table and left the room. At 10:33 AM, when asked about this medication, the nurse stated she should not have left the drink in the room because it contained medication and that she should have ensured the resident drank all of it. A third resident, admitted with gastroesophageal reflux disease, had a physician’s order dated 03/19/26 for calcium carbonate 600 mg by mouth in the morning as a supplement. On 03/24/26 at 8:45 AM, a nurse prepared and administered calcium carbonate 1000 mg instead. Later that day, review of the medication bottle showed tablets labeled 1000 mg, and the nurse stated she did not think calcium carbonate came in 600 mg tablets and would inform the provider about the dosage.
Medication Administration Errors Result in Exceeding 5% Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors in 28 medication administration opportunities, resulting in a 7.14% error rate. For one resident with diabetes mellitus who was cognitively intact and received insulin injections daily, the physician’s order directed administration of insulin aspart 23 units SQ with meals. During observation of a medication pass, an LPN removed the insulin aspart pen from the cart, dialed the pen directly to 23 units, attached the needle, and administered the dose without priming the pen. The LPN confirmed she did not prime the pen and acknowledged that her usual practice would be to prime the pen, then dial the required dose, then place the needle on the pen. Manufacturer instructions for the KwikPen specified that the pen must be primed before each injection by selecting 2 units, holding the pen needle-up, tapping to move air bubbles, and pushing the dose knob until insulin is seen at the needle tip before dialing the prescribed dose. In a separate incident, another resident with Crohn’s disease, diverticulosis, constipation, severe cognitive impairment, and frequent bowel incontinence had a physician’s order for MiraLAX powder 17 g PO once daily. During an observed medication administration, an LPN measured the MiraLAX powder by filling the product cap only to just under the very bottom line inside the lid, then poured this amount into water for administration. When asked to read the product instructions, the LPN reviewed the MiraLAX container, which stated that the bottle cap is a measuring cup designed to contain 17 g when filled to the top rim. The LPN confirmed that the MiraLAX had not been measured according to the manufacturer’s instructions. These two observed medication administration errors formed the basis of the cited deficiency under the referenced complaint investigation.
Medication Administration and Documentation Errors Result in Elevated Medication Error Rate
Penalty
Summary
Surveyors determined that the facility failed to maintain a medication error rate below 5%, with an observed rate of 6.45%. During a medication pass observed at 9:18 AM, a registered nurse administered multiple medications, including Lasix 20 mg, a multivitamin, MiraLAX 17 g, Duloxetine 60 mg, allopurinol 100 mg, carvedilol 3.125 mg, vitamin B12, and lisinopril 5 mg. A subsequent review of the medication administration record at 12:38 PM revealed that Duloxetine 60 mg, ordered as a delayed-release capsule to be given by mouth at bedtime for depression, was instead administered during the morning medication pass. The review also showed an active order for Famotidine 20 mg by mouth once daily in the morning for GERD, which was not observed being administered during the medication pass but was documented on the medication administration record as having been given. These observed discrepancies between physician orders, actual medication administration times, and documentation on the medication administration record constituted medication errors that contributed to the facility’s medication error rate exceeding the 5% threshold.
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