F0684

E

Widespread Medication Errors, Inaccurate Documentation, and Missed Neuro Checks

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

Penalty

No penalty information released

Summary

Surveyors identified multiple failures to provide treatment and care according to orders, resident preferences, and professional standards, resulting in missed medications, inaccurate documentation, administration of medications without appropriate parameters, and incomplete neurological assessments after unwitnessed falls. One cognitively intact resident with end stage renal disease and chronic pain was observed during a morning medication pass where an LPN documented administration of several medications and a daily weight that had not actually been given, including a lidocaine patch, Lokelma, sevelamer, and Colace. The resident declined sevelamer until after breakfast, and the LPN removed the tablets and stored them in the cart but still documented them as administered and later confirmed she never returned to give the dose or corrected the record. The same resident reported not receiving the lidocaine patch or her daily weight, and record review showed daily weights had not been documented for over a week.

The same resident had an order for midodrine for hypotension, including a scheduled dose and a PRN dose, but the order lacked blood pressure parameters. During observation, the LPN administered midodrine without first assessing or documenting vital signs and later stated she believed she had taken them but could not locate documentation. The LPN acknowledged that midodrine requires a blood pressure assessment and that there were no parameters in the order, while the nurse who transcribed the order and the NP both confirmed that parameters should have been included but were missing. Another resident with type 2 diabetes and obstructive sleep apnea had a weekly Ozempic injection documented as not given because the LPN could not find the medication; there was no documentation that the provider was notified or that the medication was reordered, and pharmacy records showed no refill request had been received.

For residents who experienced unwitnessed falls, required neurological assessments were not fully documented according to the facility’s protocol. One resident had an unwitnessed fall with initiation of neuro checks, but the neuro assessment form showed missing documentation for a specified shift several days later. The same resident had another unwitnessed fall with head impact reported, and the neuro assessment record showed multiple missing entries at required times over subsequent days. Staff, including LPNs and the DON, stated that neuro checks were required after unwitnessed falls and should be documented on the neurological assessment sheet, but review confirmed missing documentation that could not verify completion of all required assessments.

Another cognitively intact resident who went to dialysis three times weekly had treatment documentation completed by an RN for a shift when the resident was not in the building. The RN documented that the resident had no episodes of sadness or loneliness, that the dialysis site and port were monitored and intact, and that enhanced barrier precautions were maintained throughout the shift, even though the resident had left for dialysis before the RN’s shift began and did not return until midday. In a separate incident, an agency LPN left mid‑shift without notifying leadership, locking medication cart keys in the med room and failing to administer scheduled HS medications to multiple residents. A subsequent review showed that numerous residents each missed several scheduled nighttime medications, and a replacement nurse arriving hours later confirmed that none of the HS medications for a group of rooms had been given and that it was too late to administer them.

Another cognitively intact resident with conjunctivitis had ongoing eye infection signs, including green drainage and red, irritated sclera in both eyes, observed on multiple days. The resident did not have a current antibiotic order despite visible symptoms. Record review with the unit manager and infection preventionist showed that the resident had been ordered gentamycin eye drops twice in recent weeks, but doses were missed on days when the resident was at dialysis and on at least one other occasion, with refusal or missed doses not consistently documented in progress notes. There was no evidence that the physician was notified of missed antibiotic doses, no orders obtained for late administration after dialysis, and no documentation that the provider was informed that the infection persisted. The unit manager acknowledged that progress notes and follow‑up documentation were not completed as expected and that the resident continued to have conjunctivitis because the full antibiotic course was not received.