F0759

E

Multiple Medication Administration and Transcription Errors Exceeding Acceptable Error Rate

Lakeside, Arizona Survey Completed on 11-19-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that medication error rates were below 5%, as evidenced by multiple observed and documented errors in medication administration and order transcription. For one resident with hypertension, depression, and non-Alzheimer’s dementia, surveyors observed an LPN administer a lidocaine 4% patch after first removing an existing white patch from the resident’s left lower leg, despite the MAR documenting that the previous day’s patch had been removed the prior evening. The physician’s order for the lidocaine patch specified application to the knee once daily for pain but did not include instructions for when to remove the patch. The MAR showed the lidocaine patch transcribed with an 8:00 AM application and 8:00 PM removal schedule, with documentation indicating that the patch had been removed the previous night, which conflicted with the presence of a patch still on the resident’s leg at the time of observation. For the same resident, a physician order for sertraline 100 mg once daily was in place and had been transcribed to the MAR, with documentation showing administration of 100 mg daily since the order date, yet during observation the LPN dispensed and administered only 50 mg.

Further review and interviews revealed additional details about the sertraline dosing error. A CMA stated that the resident had previously received 50 mg sertraline, and that the dose had been increased to 100 mg. She produced a new bubble pack of sertraline 100 mg and explained that it must have arrived two days earlier. She reported that she had administered two 50 mg tablets the previous day because she had not seen the new 100 mg bubble pack until then. The DON stated that when a psychotropic medication dose is changed, facility policy requires a new assessment and consent, and that the old 50 mg bubble pack should be returned to the pharmacy once the 100 mg dose is ordered. He also stated that staff are expected to follow physician orders at all times during medication administration.

Additional residents were involved in lidocaine patch administration issues. One resident with hypertension, anxiety disorder, and depression had a physician order for a lidocaine 4% patch to be applied to the ankle once daily for pain, without any schedule for removal. The order was transcribed on the MAR to be applied in the morning, but no removal time was documented. During observation, an LPN removed an existing patch from the resident’s right ankle and immediately applied a new patch to the same site. Another resident with hypertension and a UTI had a physician order for a lidocaine 4% patch to be applied to the right shoulder in the morning for pain, again without removal instructions. The MAR did not include a removal schedule, and during observation an RN removed a patch from the resident’s right shoulder and applied a new patch just below the shoulder. The DON later reviewed a lidocaine 4% patch package, which stated it was for single use, to be used for up to 12 hours and then discarded, while also stating that if no removal instructions were provided, nurses might use clinical judgment or manufacturer guidelines.

A separate medication error involved the administration schedule of furosemide for a resident with hypertension, depression, PTSD, morbid obesity, and edema. Provider progress notes documented a plan to increase furosemide to 20 mg twice daily for edema, and the physician order summary reflected furosemide 20 mg twice daily without specified administration times. However, the MAR for the month showed the order transcribed as 20 mg twice daily at 8:00 AM and 12:00 PM. On the survey date, furosemide was administered at 8:00 AM and again at approximately 11:28 AM, about 3.5 hours apart. There was no evidence in the clinical record of any physician order specifying the 8:00 AM and 12:00 PM schedule. Interviews with nursing staff, the provider, and the pharmacist indicated that standard practice for twice-daily furosemide is to space doses further apart (e.g., morning and late afternoon/evening), and the pharmacist noted that furosemide is usually given 6–8 hours apart. The LPN who administered the medication stated she had been giving it at 8:00 AM and 12:00 PM since the order was written, based on her understanding that this was how the provider wanted it scheduled, while also stating that she would normally question such a schedule. The DON confirmed that the electronic record set the twice-daily schedule and that, in this case, staff were expected to give the second dose four hours after the first, consistent with how it had been entered.