F0760

E

Multiple Missed and Incorrectly Documented Medication Doses, Including Wrong Fentanyl Patch Dose

Lake Norden, South Dakota Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to ensure residents were free from significant medication errors when one LVN documented medications as administered in the electronic MAR (eMAR) without actually giving them, and applied an incorrect dose of a Fentanyl patch to a resident. On two consecutive days, multiple residents did not receive their scheduled HS and morning medications, even though the eMAR showed the medications as given. An internal audit conducted after a resident reported receiving morning medications revealed that, on the Alzheimer Care Unit, most residents’ HS medications from the prior day remained in the bubble cards, and on the main floor, some residents’ morning medications also remained in the bubble cards despite being signed out on the eMAR. The same LVN had also applied a 25 mcg Fentanyl patch instead of the ordered 12 mcg dose to one resident.

The medication system in place used bubble cards with 30 individual “bubbles” per card and colored stickers indicating a.m., p.m., or HS passes, and nurses were expected to punch medications out of the bubble cards into a cup, administer them, and then immediately document administration in the eMAR. According to nursing staff, medications that were not administered would remain in the bubble pack for that date, and cards for a completed pass would be moved to the back of the row. However, review and interviews showed that for the HS pass on one date and the morning pass on the following date, medications for multiple residents remained in the bubble packs and the cards were not moved, even though the eMAR entries had been completed as if the medications were given. The DON stated she was not auditing bubble cards for medication errors at the time and had not previously encountered medications being signed out in the eMAR while remaining in the bubble cards before this incident.

Record review identified specific residents affected by these errors. One resident with severely impaired cognition and an order for a 12 mcg/hr Fentanyl patch every 72 hours received a 25 mcg patch instead. Another resident with severe cognitive impairment and multiple orders for antiseizure, blood pressure, antipsychotic, and other medications did not receive those HS medications, though they were signed out as given. Additional residents with varying levels of cognitive impairment and intact cognition did not receive ordered medications including antidepressants, antianxiety agents, blood thinners, seizure medications, thyroid replacement, gastrointestinal medications, supplements, and sleep aids, even though the eMAR reflected administration. The facility’s Medication Administration Policy required medications to be administered according to prescriber orders, prohibited using one resident’s medications for another, and required that the individual who administers the medication document directly after giving the dose and document any withheld or unadministered doses per procedure, which did not occur in these events.