Failure to Investigate and Correct Medication Errors Leading to Multiple Significant Drug Administration Mistakes
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough and timely investigation and to implement corrective actions after an initial significant medication error, which allowed additional serious errors to occur. Facility policy on Medication Administration, revised 12/2025, requires accurate, safe, and timely administration of medications and verification of the medication label against the medication sheet, with physician orders checked if there is any discrepancy. Despite this, one resident admitted with multiple rib fractures was initially prescribed Oxycodone 5 mg every 6 hours for pain, which was discontinued and changed to Hydrocodone 5-325 mg every 6 hours on 06/26/25. On 07/02/25, this resident was administered the previously discontinued Oxycodone, which had not been removed from circulation. Following that event, the facility did not ensure that all licensed nurses were educated on medication administration requirements before their next shifts, and two further significant medication errors occurred. One cognitively intact resident with orthostatic hypotension and Lewy body neurocognitive disorder was given another resident’s medications, including Oxycontin ER 20 mg and Amlodipine 5 mg, and required Narcan and transfer to the ED, where the resident was found to be markedly orthostatic and required IV electrolytes and hydration before transfer to another hospital when blood pressure trended low. Another cognitively intact hospice resident with COPD, chronic pancreatitis, and generalized anxiety disorder had been prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, which was discontinued on 06/19/25 but not removed from circulation. The controlled substance log showed that this resident repeatedly received the wrong dosage form (tablet instead of liquid) on multiple dates and again received the wrong form and a discontinued medication on 07/06/25. These events occurred while nurse management were aware of the initial error but had not yet ensured all licensed staff were educated prior to subsequent shifts.
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