F0760

D

Medication Transcription Errors and Delayed PRN Pain Management

Saint Louis Park, Minnesota Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves failures in medication management for two residents, resulting in significant medication errors and delayed pain control. For one resident with intact cognition and diagnoses including heart failure, orthostatic hypotension, and stroke, the facility did not verify and accurately transcribe multiple metoprolol orders from the hospital, cardiology clinic, and pharmacy. The hospital discharge summary prescribed metoprolol succinate 50 mg twice daily, but facility orders initially listed metoprolol succinate ER 50 mg once daily at 8:00 a.m. and once daily at 8:00 p.m., and the MAR showed administration twice daily with one undocumented omitted dose. Later, a cardiology provider note recommended increasing metoprolol succinate to 75 mg daily, while a cardiology order from the same visit directed 75 mg twice daily. Facility orders were entered as metoprolol succinate ER sprinkles 25 mg, 3 tablets twice daily, without documentation that staff clarified the discrepancy between the provider note and the cardiology order or reconciled these with the original hospital order.

Subsequently, pharmacy provider orders indicated metoprolol succinate ER 50 mg once daily, but facility orders added metoprolol tartrate 50 mg daily instead of metoprolol succinate, creating duplicate and conflicting orders. The MARs for January and February documented administration of both metoprolol succinate 75 mg twice daily and metoprolol tartrate 50 mg daily over several days, and continued twice-daily dosing of metoprolol succinate despite conflicting once-daily versus twice-daily directions. Nursing progress notes lacked evidence that staff clarified the conflicting and duplicate orders. Interviews with the NP and nursing staff confirmed that duplicate metoprolol orders existed, that metoprolol tartrate was ordered instead of succinate, that the nurse entering the order did not know the difference between the two formulations, and that required second and third verification checks for telephone orders were not completed. The NP and pharmacist stated that the resident received double the prescribed dose of metoprolol, and the resident reported feeling sicker, experiencing dizziness, and being told by both the cardiology provider and NP that she had been receiving the wrong dose.

For a second resident admitted after cervical spinal fusion surgery, the facility failed to timely administer prescribed PRN opioid pain medication. Hospital discharge orders and facility provider orders included oxycodone 5 mg every 4 hours PRN for pain and acetaminophen 325 mg, 2 tablets every 4 hours PRN for mild pain. The admission assessment and pain evaluation documented that the resident had occasional pain that affected sleep, therapy, and daily activities, and the baseline care plan identified pain/comfort issues with a goal for adequate pain relief. However, the MAR showed that oxycodone was not administered until the evening after admission, and acetaminophen was not documented as given on the MAR despite a progress note stating it was administered. Progress notes indicated that a family member requested pain medication when the resident rated pain as 7/10, that the nurse had to call a provider to request an oxycodone order, and that oxycodone was then administered twice within a time frame that was too close for the every-4-hours PRN order. Interviews with the resident, family member, NP, LPN, and DON described that the resident arrived in significant pain, that pain medication was not available when he arrived, that he waited over 24 hours for pain relief, and that staff did not follow existing processes to obtain pain medications from the pharmacy or the facility’s medication bank upon admission.