F0760

D

Significant Medication Errors and Failure to Follow Physician Orders

Sylvania, Ohio Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure medications were administered in accordance with physician orders, resulting in significant medication errors for multiple residents. One resident with extensive medical conditions including cerebrovascular disease, type II diabetes, epilepsy, hypertension, chronic pain, cortical blindness, and morbid obesity had an active order for morphine sulfate oral solution 20 mg/mL, 0.5 mL by mouth every two hours as needed for pain or shortness of breath, and no active order for Dilaudid. Event documentation for this resident noted an incident in which the resident was sitting in a recliner, reported pain, and was found to have oxygen saturation below 90%, requiring application of as-needed oxygen to return saturation above 90% on 2.5 L via nasal cannula. The documentation referenced that medication was not administered according to the six rights of medication administration, but did not specify the medication or dose given, nor did it contain detailed content of the incident, ongoing assessment of the resident’s health status, or physician instructions.

Further information obtained through interview with the DON and the Administrator revealed that an LPN reported administering two different doses of Dilaudid in error to this resident instead of the ordered morphine. The DON was unable to identify the resident for whom the Dilaudid had been prescribed and there was no documentation in the medical record of the specific medication or dose administered. The DON also stated she did not check the Dilaudid suspension level before or after the LPN’s shift, and concluded that the LPN did not identify the correct medication before administration. The medical record lacked additional progress notes related to this medication error in the days following the incident.

Another deficiency involved a resident with an order for metoprolol succinate ER 25 mg once daily for hypertension related to hypertensive chronic kidney disease, with instructions to hold the medication if systolic blood pressure was less than 100 mmHg or heart rate less than 60 beats per minute. Observation showed an RN preparing and administering this medication without obtaining vital signs beforehand, and the RN confirmed that no vital signs were taken prior to administration. A third resident had an order for cephalexin 500 mg by mouth four times daily for cellulitis, scheduled at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M., with facility policy specifying that such antibiotics must be administered at equally spaced times. Observation showed the RN administering the cephalexin at 9:19 A.M., outside the prescribed timeframe, and the RN confirmed the medication was given outside the ordered schedule. These actions were inconsistent with the facility’s medication administration policies requiring adherence to physician orders and specified timing.