Medication Given Outside BP Hold Parameters
Summary
The facility failed to ensure Labetalol Hydrochloride was held according to the ordered parameters for one resident. The resident was admitted with diagnoses including hypertensive heart disease with heart failure and cerebral infarction, and the MDS indicated intact cognition and dependence on staff for showers/bathing self and toileting hygiene. The MAR for March 2026 directed staff to hold Labetalol HCL if systolic BP was below 110 or diastolic BP was below 60, with those parameters in place since 11/11/2024. During a medication administration observation, an LVN checked the resident’s BP on the right wrist and then the left wrist, with the BP reading 117/58 mm Hg. Despite the diastolic pressure being below the hold parameter, the LVN administered 300 mg of Labetalol HCL with other scheduled medications. In a concurrent interview, the LVN stated the medication was given outside the holding parameters and acknowledged it could lower the resident’s DBP and potentially cause weakness and dizziness. The DON stated the facility did not have a policy and procedure on significant medication errors and confirmed that administering Labetalol outside the parameters was a medication error.
Plan Of Correction
Significant Medication Errors Root Cause:The root cause of the deficient practice was failure of licensed nursing staff to consistently follow physician-ordered holding parameters prior to medication administration, including inadequate review of vital signs and lack of clear documentation of clinical decision-making. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 3/11/2026, for Resident #5, the Physician was immediately notified of the medication administration outside of holding parameters. The resident's blood pressure was monitored closely for 24 hours, and no adverse effects were observed. The resident's care plan and medication administration instructions were reviewed with licensed staff to ensure clarity of holding parameters. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 3/31/2026, the Director of Nursing (DON) and designee conducted a random audit of residents receiving medications with holding parameters over the past 30 days, verifying that medications were administered in accordance with physician orders and documented appropriately.No additional residents were identified to be out of compliance. Any discrepancies, if identified, would have been immediately corrected, including physician notification, documentation update, and staff re-education. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: To prevent recurrence, the facility implemented the following systemic changes:On 3/30/2026, the DON conducted mandatory in-service training for all licensed nursing staff on medication administration protocols, including: Strict adherence to physician-ordered holding parameters Requirement to obtain and review vital signs prior to medication administration Clinical decision-making regarding whether to administer or hold medications Medication Administration Verification Process:Licensed nurses must verify current vital signs (e.g., blood pressure, pulse) and compare them directly to physician-ordered parameters prior to administering medications.If parameters are not met, the medication must be held, and the Physician notified as appropriate.Documentation Expectations:Licensed nurses must document:Vital signs obtained prior to administration Comparison to ordered parameters Clinical decision to administer or hold the medication Accurate MAR documentation, including reason for holding when applicable Accountability:Licensed Nurses: Responsible for medication administration, parameter verification, and documentation DON/Designee: Responsible for oversight, compliance monitoring, and enforcement Completion Date: 4/13/2026 How the facility plans to monitor its performance to ensure that solutions are sustained: The facility will maintain a 100% compliance threshold for medications administered with holding parameters. Monitoring Plan: The DON or designee will conduct weekly audits of a minimum of 5 residents receiving medications with holding parameters for 4 weeks, followed by monthly audits for 2 months. Audits will verify: Presence of documented vital signs prior to medication administration Comparison of vital signs to physician-ordered parameters Confirmation that medications were held when parameters were not met Accurate and complete MAR documentation, including rationale for administration or holding Corrective Action Loop: Any identified noncompliance will be corrected immediately, including physician notification if indicated and documentation correction. The responsible licensed nurse will receive re-education prior to the end of the shift. A follow-up audit within 24 hours will be conducted to ensure compliance. Repeated noncompliance will be addressed through progressive discipline per facility policy. Reporting & Oversight: Audit findings will be reported weekly to the DON and Administrator during the monitoring period. Results will be presented at the monthly Quality Assurance (QA) Committee Meeting. The QA Committee will monitor compliance monthly until sustained 100% compliance is achieved. Responsible Parties: Licensed Nurses: Medication administration, parameter verification, and documentation DON/Designee: Oversight, audits, and enforcement Completion Date: 4/13/2026
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Significant morphine dose error: An RN administered 0.25 mL (5 mg) of morphine sulfate buccally instead of the ordered 0.1 mL (2 mg) dose to a resident with severe cognitive impairment, Alzheimer’s disease, CAD, and dementia. The RN said she followed the medication box label, while the unit manager confirmed the correct dose was on the EMAR. The resident was assessed afterward and remained unchanged.
An LPN administered Humalog insulin to a resident with stroke, aphasia, and diabetes without priming the insulin pen as required by manufacturer instructions. The LPN dialed the ordered 5-unit dose but did not prime the pen with 2 units before injection, and later stated she was unaware of the need to prime it. The DON confirmed insulin pens should be primed according to the manufacturer's instructions.
A resident with CHF and dysphagia had a medication error when an MA crushed and administered multiple morning meds, including Potassium Chloride ER, despite a provider order that it not be crushed. The facility policy required meds to be given as ordered and prohibited crushing do-not-crush, slow-release, and enteric-coated meds; the record also identified potassium chloride as a high-alert medication.
Two residents experienced significant medication errors when ordered meds were not available or not administered as prescribed. One resident on hospice went more than 24 hours after admission without ordered Morphine for pain and air hunger, while another resident missed multiple doses of a Lidocaine patch and Mirabegron because the meds were out of stock or not obtained from the pharmacy, with the DON confirming the missed doses and unrelieved pain were significant.
A resident with moderately impaired cognition and cerebral amyloid angiopathy had a weekly buprenorphine patch order inaccurately transcribed as Suboxone on the MAR. Staff also applied a new pain patch without removing the old one, leaving two active patches on the resident for several days. The DON stated the admission verification process was not followed and the incident was not investigated.
A resident with DM2 and multiple chronic conditions had an order for daily insulin glargine, but an RN documented that the dose was not given because the medication was unavailable. An LPN stated staff should reorder meds when five doses remain and, if out, notify the provider and pharmacy and use the emergency medication supply system; an RN and the DON confirmed backup insulin was available in a lockbox, and the DON noted there was no documentation explaining the omission.
Significant morphine dose error
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when an RN administered 5 mg of morphine sulfate instead of the prescribed 2 mg dose. The resident had severe cognitive impairment and diagnoses that included Alzheimer's disease, coronary artery disease, and dementia. The physician orders directed morphine sulfate concentrate oral solution 100 mg/5 mL to be given as 2 mg (0.1 mL) buccally every four hours for pain, with a separate PRN order for 5 mg (0.25 mL) buccally every hour as needed for breakthrough pain or shortness of breath. The EMAR showed the resident received the scheduled 2 mg dose at 4:00 p.m. and did not show a PRN 5 mg dose. During observation, RN-B withdrew 0.25 mL of morphine sulfate using the syringe provided with the medication and administered it buccally to the resident, then documented on the narcotic record book that 0.1 mL had been given. RN-B stated she gave 0.25 mL because the medication box label identified 0.25 mL, while RN-A stated the correct dose was 0.1 mL and acknowledged the error after RN-B confirmed the amount administered. The resident was assessed after the error and remained unchanged, with vital signs and condition stable. The DON stated the medication label had been followed instead of the EMAR, and the consultant pharmacist stated the resident could have experienced increased drowsiness from the error.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when it did not follow insulin pen preparation instructions for Resident #8. Resident #8 was admitted with multiple diagnoses including cerebral infarction (stroke), aphasia, and diabetes, and had a physician order for Humalog (Lispro) insulin pen-injector 100 units/ml to be injected subcutaneously at 5 units before meals for type 2 diabetes. During observation on 8/4/26, an LPN removed the Humalog insulin pen from the medication cart and dialed it to the ordered 5 units, but did not prime the pen with 2 units before administering the dose. The insulin was then given to Resident #8. When interviewed shortly afterward, the LPN stated she did not prime the insulin pen and was unaware of the need to do so before administering insulin. The DON stated insulin pens should be primed according to the manufacturer's instructions and had not been.
Significant medication error involving crushing a do-not-crush ER medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a Medication Aide crushed and administered medications that included Potassium Chloride ER, despite a physician order stating the medication was to be given by mouth twice daily and not crushed. The resident had diagnoses of chronic diastolic heart failure and dysphagia following a cerebral infarction, and the physician’s orders contained no instruction to crush medications. The facility policy stated medications should be administered as ordered and that medications with do-not-crush instructions, including slow release and enteric coated medications, should not be crushed. During observation, the Medication Aide confirmed they were going to crush all of the resident’s morning medications except Pantoprazole. The aide then placed Clopidogrel, Potassium Chloride ER, Sertraline, and Torsemide into a medication cup, crushed them, added pudding, and fed the mixture to the resident. The record review also identified Potassium Chloride as a high alert medication and cited guidance stating that enteric-coated or extended-release tablets or capsules should not be chewed or crushed.
Significant medication errors from delayed and missed ordered medications
Penalty
Summary
The facility failed to obtain physician-ordered medications in a timely manner, resulting in significant medication errors for two residents. One resident was admitted to the facility on 7/9/26 under hospice care with end-stage heart failure and had an order for Morphine Sulfate concentrate 10 mg sublingually every hour as needed for pain and/or air hunger. The resident did not receive Morphine on the day of admission, and the first documented dose was not given until 7/10/26 at 1:41 p.m., about 26 hours after admission. The MAR documented 26 potential missed PRN doses, and the resident’s family member and an LPN stated the medication was not available when needed and that the resident had signs of pain during that period. A second resident had orders for a Lidocaine external patch once daily for mild pain and Mirabegron ER 25 mg daily for urinary antispasmodic use. The MAR and nursing notes documented that the Lidocaine patch was not administered for multiple days because it was out of stock, with missed applications documented on 7/26, 7/27, 7/29, and 7/30, and 7/28 signed in error as given. The resident stated the missed patches prevented comfortable sleep. The same resident also missed Mirabegron doses on multiple days because the medication was on order from the pharmacy and not available, with documentation showing missed administration on 7/14, 7/15, 7/16, 7/17, 7/19, 7/20, and 7/21, and one date documented as given in error. The DON confirmed the Lidocaine order did not include a dose and acknowledged the resident missed several doses because the facility ran out of the patches. The DON also confirmed the Mirabegron was not supplied as expected and that the convenience box did not contain that medication. The resident and family member stated the missed medications affected pain control, sleep, and urinary urgency, and the DON stated the quantity of missed doses and unrelieved pain equated to significant medication errors.
Medication Order Transcription Error and Duplicate Pain Patch Application
Penalty
Summary
The facility failed to ensure a resident remained free from significant medication errors when admission medication orders were not accurately transcribed to the MAR. The resident was admitted with diagnoses including cerebral amyloid angiopathy, and the comprehensive assessment showed moderately impaired cognition and a need for assistance from one staff member with ADLs. The hospital discharge orders included a weekly buprenorphine transdermal patch, but the July 2026 MAR listed the medication as a weekly Suboxone transdermal patch instead. Staff later stated the wrong medication name was entered because Suboxone was believed to be the same medication as buprenorphine, and the admission body check was not completed to determine whether a transdermal patch was already present. The resident representative reported that facility staff applied a new pain patch without removing the old one, leaving two active patches on the resident for three days. Staff later confirmed one patch was on the right shoulder and another on the left shoulder, and the older patch was then removed. The DON stated the facility’s medication error process included staff interviews, physician notification, alert charting, and monitoring for high-alert medications, but also stated the incident was not investigated and no medication error report was completed. The DON further stated the admission process required a three-step verification of orders, and that process was not followed for this resident.
Missed Insulin Dose Due to Medication Unavailability
Penalty
Summary
A resident with type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and obesity had a physician order for Insulin Glargine Solostar 300 units/mL, 50 units subcutaneously once daily. On 3/20/26 at 11:19 AM, an RN documented that the insulin was not administered because the medication was unavailable. During interviews on 7/30/26, an LPN stated that medications should be reordered through the eMAR when five doses remain and that if a medication is completely out, staff must immediately notify the provider and pharmacy and use the emergency medication supply system. An RN confirmed that backup insulin was available in a lockbox in the third-floor refrigerator and that staff should not run out of insulin. The DON also confirmed the backup insulin location and the pharmacy restocking alert system, and stated there was no documentation in the progress notes or TAR explaining the omission; because she was not employed at the facility at the time, the exact reason for the unavailable medication and omitted dose remained unknown.
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