F0760

G

Failure to Ensure Accurate Medication Administration and Dosing for Multiple Residents

Ankeny, Iowa Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures in medication administration that resulted in residents not receiving medications as ordered and, in one case, receiving another resident’s medications. One resident with a history of stroke, cognitive communication deficit, and urinary tract infection was involved in a room change. On the morning of the incident, an RN retrieved medications from the medication cart using the room slot labeled for that room, but did not verify the resident’s name on the medication packs or compare the medications to the MAR. The RN popped, crushed, and administered a full set of medications that belonged to a different resident, including several antihypertensives, an anticoagulant, and other medications not prescribed for this resident. Shortly afterward, the resident appeared pale, with head drooping and unable to speak, and was found to have low blood pressure and heart rate. The facility’s investigation documented that the RN had taken medications from the wrong room spot in the cart after the room change and that the investigation lacked documentation of staff or resident interviews about past or present concerns with medication administration.

A second deficiency involved another resident with dementia who was cognitively intact per BIMS. On one occasion, a medication (Donepezil 10 mg) arrived from the pharmacy after the CMA had already passed the resident’s morning medications. The RN administered the newly arrived dose but did not immediately sign it out on the MAR and left the medication at the cart between the computer components instead of securing it. While the RN was away in the DON’s office, the CMA, seeing the unsigned medication and not recognizing it had already been given, administered the same medication again and signed it on the MAR. This resulted in a double dose of the medication due to failure to document administration at the time of giving and failure to secure the medication on the cart.

A third deficiency involved a resident admitted after digestive system surgery with rectal cancer, anemia, diabetes, a surgical wound, and significant pain. The resident had orders for Tramadol 100 mg PO every 6 hours for pain management, initially PRN and then scheduled. Due to a discrepancy between the physician’s order and the pharmacy-supplied bubble packs, staff administered only 50 mg every 6 hours over several days instead of the ordered 100 mg dose. Documentation showed that the controlled drug receipt forms and bubble pack labels reflected 50 mg tablets, and staff followed the bubble pack directions rather than the computer order. The MAR documented Tramadol 100 mg as given, but only 50 mg was actually administered on multiple occasions. Staff did not compare the bubble pack contents and labeling to the physician’s order in the computer prior to administration, and the error was discovered only after the resident continued to report significant pain and wound dehiscence was noted. Interviews confirmed that nurses and CMAs were expected to follow the 6 rights of medication administration and compare bubble packs to physician orders, but in this case they relied on the bubble pack directions instead of the actual order.