F0760

D

Significant Medication Errors Involving Unauthorized Nitroglycerin and Wrong IV Antibiotic

Bellbrook, Ohio Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically involving two residents who received medications not in accordance with prescriber orders. One resident with diagnoses including cerebral infarction, paroxysmal atrial fibrillation, hypertensive urgency, adult failure to thrive, and essential hypertension, and who had moderately impaired cognition, reported severe chest pain rated 9/10 one morning. Documentation in the resident’s progress and SBAR note showed the resident was sent to the emergency department after the onset of chest pain and that the primary care clinician (a nurse practitioner) was notified, but there was no documentation of any medication administered in response to the chest pain in the medical record.

An incident report prepared by the DON documented that the resident complained of chest pain, vital signs were taken, the NP was called, and that medication was given to the resident without an order before the resident was sent to the ER. A hospital history and physical note recorded that the patient stated they had been given a dose of sublingual nitroglycerin prior to coming to the emergency department. The NP later stated that, to their knowledge, the resident was given sublingual nitroglycerin without an order and that facility staff called after the medication had already been administered, asking for an order to be placed retroactively, which the NP did not do. The DON reported being aware that sublingual nitroglycerin had been administered without an order and that no nurse on duty would admit to giving the medication, while a CNA reported witnessing an LPN place a medication under the resident’s tongue in response to the chest pain. Review of the resident’s physician orders and MAR for the month showed no order for sublingual nitroglycerin.

The second resident involved had diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, diffuse traumatic brain injury with loss of consciousness, essential hypertension, anxiety, and a more recent diagnosis of sepsis due to MRSA. The facility’s Incident and Accident Log documented a medication error for this resident on one date, indicating that the wrong antibiotic had been administered. An incident report showed that the resident was given IV ceftriaxone instead of the ordered IV cefepime, and that the incorrect antibiotic infusion ran for approximately five to ten minutes before being stopped. The report indicated that a trainee nurse obtained the wrong antibiotic from the medication refrigerator and started the infusion after verifying the resident’s name, medication, and dose with another nurse who was training them. Review of the MAR confirmed an active order for IV cefepime and no order for IV ceftriaxone. The DON confirmed that a medication error occurred when the wrong antibiotic was administered. The facility’s policy on administering medications required that medications be administered in accordance with prescriber orders, which was not followed in these instances.