F0760

G

Significant Medication Errors from Mis-transcribed Antipsychotic Orders and Missed Doses

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, including incorrect transcription and administration of antipsychotic injections and omission of ordered medications. One resident with paranoid schizophrenia and a cognitive communication deficit was admitted with an order for haloperidol decanoate 250 mg IM every 21 days. An LPN entered the order into the electronic record incorrectly as 2.5 mL IM "one time a day starting on the 16th and ending on the 21st every month," which resulted in multiple injections being scheduled and administered within a short period instead of a single injection every 21 days. The MAR showed that the resident received haloperidol decanoate injections on multiple days in February, and the facility’s own investigation confirmed that the order was transcribed incorrectly. The resident’s family member reported noticing a decline in the resident’s condition after these multiple injections, including decreased participation in therapy, increased tremors, and confusion. Therapy documentation from the last two weeks of February noted downgraded tasks due to difficulty with fine motor tasks, poor sequencing, increased confusion, and lethargy.

The same resident’s outside mental health provider discovered the error when the resident presented for her usual monthly medication review and reported she had already received the injection at the facility. The mental health nurse requested medication records and later called the facility to review the orders. During that call, an LPN at the facility read the incorrect haloperidol order and acknowledged that the resident had received multiple doses within a week. The mental health nurse documented that the LPN stated he thought the order looked unusual, had asked a supervisor for clarification, and was told to administer the medication as written. The LPN later documented in a progress note that the order in the electronic record was incorrect and that he had administered two doses, but he did not clearly recall when he reported the incident internally or whether the physician was notified at the time. The facility pharmacist stated that the resident’s total monthly dose exceeded the typical effective range and described specific clinical risks associated with excessive haloperidol dosing.

Another resident with schizoaffective disorder, depressive type, had a care plan intervention to administer medications as ordered and monitor for side effects and effectiveness. This resident had an order for haloperidol decanoate 2 mL IM every 28 days with instructions to inform the social worker, DON, and provider if the injection was refused. The MAR showed the injection was documented as refused by an LPN, but there was no documentation that the social worker, DON, or provider were notified, and the injection was not subsequently administered. Staff interviews indicated that this resident experienced increased behaviors, including more frequent screaming out, attempts at self-transfer, refusals of care, verbal aggression, and falls during the following weeks. Progress notes documented refusals of care, self-transfers, delusional statements, and an IDT note referenced recent falls and delusional statements, with a psychiatry follow-up note explicitly stating that the resident had not received the scheduled haloperidol injection and that this was likely contributing to her current decompensation.

Additional residents experienced omitted medications when an agency LPN left mid-shift without notice and failed to complete assigned medication administration duties. The facility’s investigation summary and medication error log for that date showed that multiple residents did not receive scheduled HS medications. One resident did not receive doses of Seroquel, Keppra, and Topamax; another did not receive a dose of oxycodone; another missed doses of metoprolol and Norco; another did not receive a dose of Lasix; another did not receive risperidone; and another did not receive olanzapine. These omissions were identified as significant medication errors based on the potential to jeopardize residents’ health and safety. The facility’s medication administration policy required medications to be administered according to physician orders and standards of practice, and required documentation of refusals and physician notification as clinically indicated, but the documented events show that medications were either administered contrary to the prescribed frequency or not administered or followed up as ordered.