F0760

D

Multiple Medication Administration and Order-Entry Errors Affecting Three Residents

Wilmington, North Carolina Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple significant medication errors affecting three residents. One resident with chronic osteomyelitis and diabetes had a physician order dated 2/13/26 for doxycycline 100 mg by mouth twice daily indefinitely. Review of the March 2026 MAR showed that eight consecutive doses of doxycycline, both midday and evening, were not administered over four days, with nurses documenting that the medication was unavailable, awaiting pharmacy delivery, or awaiting refill. Several nurses who were assigned to the resident during this period acknowledged that the ordered antibiotic was not given and reported that they did not contact the pharmacy to obtain the medication, or only did so after multiple missed doses. The physician later stated she had been unaware that eight doses were missed and characterized the failure to administer the prescribed antibiotic as a significant medication error.

A second deficiency involved a resident admitted with major depression and Parkinson’s disease. The hospital discharge summary ordered mirtazapine 15 mg, one-half tablet by mouth at 11:00 PM. However, on 2/27/26 the DON entered an order in the electronic record for mirtazapine 15 mg by mouth at bedtime, resulting in the resident receiving a full 15 mg tablet nightly instead of the intended 7.5 mg dose. The MAR from 2/27/26 through 3/10/26 showed that 15 mg doses were administered each night, and there was no documentation during that period of any clarification or correction of the dose by the prescriber. The DON later stated she had transcribed the order incorrectly and that the facility’s two-step verification process for new orders was not completed for this medication.

A third deficiency concerned a resident admitted with pruritus who had a physician’s order dated 7/10/23 for hydroxyzine 25 mg three times daily. A consultant pharmacist’s medication regimen review dated 1/12/26 noted that the physician had signed a prior pharmacy consult report from 12/12/25 to change the hydroxyzine to 25 mg every morning and midday and discontinue the three-times-daily schedule, and requested that the electronic record be corrected and the medication error reported. Despite this, the MAR from 12/12/25 through 1/18/26 showed the resident continued to receive hydroxyzine 25 mg three times daily. The physician’s order in the electronic record was not updated to twice daily until 1/19/26. The DON stated she was new to the role, received the monthly pharmacist reviews, and did not promptly address the December report, resulting in the resident continuing on the higher frequency dosing until the order was finally changed.

Across these three cases, surveyors identified failures in ensuring medications were available and administered as ordered, accurate transcription of physician orders, and timely implementation of pharmacist-recommended order changes. The pharmacy manager stated that the pharmacy had systems for daily medication availability and backup processes, and acknowledged the potential risk associated with missing multiple doses of an antibiotic. The DON stated she expected medications to be administered as ordered and that nursing staff should contact the pharmacy when medications were not available, but in these instances, staff either did not contact the pharmacy in a timely manner or did not correct orders in the electronic record, leading to prolonged deviations from prescribed regimens.