F0760

E

Widespread Medication Administration Errors and Omissions

Bellingham, Washington Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a functioning medication administration system that ensured medications were given according to provider orders, not omitted, and administered in accordance with the facility’s stated ten rights of medication administration. The facility’s policy on medication pass required all morning medications to be administered between 6:00 AM and 11:00 AM and referenced ten rights to medication administration, but did not define what those ten rights were. The facility’s policy on medication incidents and errors defined an omission as any dose of medication not delivered to the resident. For one resident receiving Fosfomycin Tromethamine 10 grams every 10 days for UTI prophylaxis, the MAR showed doses given on 02/10/2026 and 03/02/2026, with a code on 02/20/2026 directing staff to see the nurse’s notes. The nurse’s note documented a call to the pharmacy about the medication and that the pharmacy would send as much as insurance allowed, but there was no evidence the 02/20/2026 dose was administered, resulting in a 20‑day gap between doses. The administrator and DON were not aware of this omitted dose.

During a continuous medication pass observation, an LPN prepared six morning medications for another resident, including duloxetine, Tylenol, thyroid medication, a stimulant laxative, a gout medication, and a medication for an autoimmune disease. The LPN separated the duloxetine into one cup and the remaining medications into another, did not check expiration dates, entered the resident’s room without knocking, did not verify the resident’s identity, and addressed the resident only by first name. When the resident asked what the first cup of medications contained, the LPN first stated it was duloxetine and Tylenol, then, after the resident did not understand and asked again, stated it was Tylenol; the resident then took the two pills. When handing the second cup, the LPN again told the resident it was Tylenol when asked what the medications were. In a subsequent observation with a different resident, the same LPN took an acidophilus capsule from a house‑supply bottle without checking the expiration date, admitted they did not check expiration dates because the cart was filled at the beginning of the year, and then prepared additional medications. The LPN entered the resident’s room without knocking, did not verify the resident’s name, administered medications one by one with a spoon, and each time only stated, “this is your medication,” without identifying the medication name or purpose.

Interviews with multiple nursing staff showed they could not correctly state the facility’s ten rights of medication administration, each listing only five or six rights, and the DON stated they would have to follow up on what the ten rights were. Review of MARs for several residents showed no documentation that scheduled 8:00 PM or HS medications were administered on 03/15/2026. One resident had no documentation of receiving a cholesterol‑lowering medication, a pain medication, and a probiotic; another had no documentation of an anti‑anxiety medication and an overactive bladder medication; another had no documentation of a cholesterol‑lowering medication, stimulant laxative, antipsychotic, and blood pressure medication; another had no documentation of an antiviral, glaucoma eye drops, a cholesterol‑lowering medication, and a nerve pain medication; and another had no documentation of an overactive bladder medication or blood sugar monitoring. When interviewed, the administrator and DON initially stated there had been no medication errors since surveyors arrived, and the DON, who passed medications on the PM shift on 03/15/2026, believed they had administered the HS and/or 8:00 PM medications. They were informed that the sampled residents’ MARs showed omitted medications and that only a small sample of residents on that hallway had been reviewed.