F0580

D

Failure to Notify Practitioner and Family After Significant Medication Error

Grand Rapids, Michigan Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely notification of a significant medication error to the resident’s practitioner and family, which resulted in a lack of assessments and monitoring. A resident with paranoid schizophrenia and a cognitive communication deficit was admitted with a care plan that included administration of medications per physician orders. An LPN entered an incorrect order for Haloperidol Decanoate, transcribing it as a daily intramuscular injection over several days each month instead of a single injection every 21 days. This transcription error led to multiple Haldol injections being administered within a short period, as documented on the MAR and confirmed by staff interviews and records.

The error was first identified externally when the resident’s Local Mental Health Authority (LMHA) nurse attempted to administer the monthly Haldol injection and was told by the resident that she had already received it at the facility. The LMHA nurse requested medication records and later called the facility to review the resident’s medications. During that call, the LMHA nurse learned from an LPN that the order had been written incorrectly and that multiple doses had been given within a week. The LPN acknowledged that the order “looked weird,” stated he had asked a supervisor for clarification, and reported he was instructed to give the medication as written. The LMHA nurse documented that the resident had received multiple doses and that the LPN believed she had received at least two doses from him.

Despite becoming aware of the medication discrepancy during the medication review with the LMHA nurse, the LPN did not promptly notify the facility’s provider, the resident’s guardians, or nurse managers. The LPN later documented the conversation and discrepancy in a progress note several days after the LMHA call, and he could not recall if he had contacted the physician about the error. The resident’s family member reported learning of the multiple Haldol doses from the LMHA and stated that the facility did not contact her until days later, after she had already been informed by the LMHA. The nurse practitioner reported she was not notified of the medication errors until a later date, by which time the resident was planning discharge. The nursing home administrator confirmed that the facility discovered the medication error days after the LPN had been informed by the LMHA nurse, and that the LPN had not notified the provider, guardians, or nurse managers when he first became aware of the errors.