Significant Medication Error and Systemic Failures in Resident Identification
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to implement effective procedures to accurately identify residents prior to medication administration. Facility policy required that medications be administered by licensed nurses in accordance with professional standards and that residents be identified by photograph in the electronic health record before medication administration. The admission policy also required that a resident photograph be obtained and uploaded to the electronic health record to ensure accurate identification. Despite these policies, the facility did not consistently maintain resident photographs in the electronic health record and did not have a reliable alternative identification process, particularly for cognitively impaired residents and for staff unfamiliar with the residents. One critical event involved two cognitively impaired residents who shared a room. One resident, admitted with senile degeneration of the brain and a BIMS score of 5 indicating severe cognitive impairment, had physician orders for morphine sulfate concentrate 20 mg/ml, 0.5 ml by mouth once daily, and levothyroxine sodium 25 mcg daily in the morning. The roommate, admitted with dementia and a BIMS score of 3 indicating severe cognitive impairment, did not have these medication orders. An agency RN, on her second shift in the facility and unfamiliar with the residents, entered the shared room to administer medications, called out the name of the resident for whom the morphine and levothyroxine were ordered, and the roommate responded "huh." Without verifying identity using a photograph or another reliable method, the nurse administered the morphine sulfate 0.5 ml and levothyroxine 25 mcg intended for the first resident to the roommate. After administering the medications, the agency RN realized at the computer that the medications had been given to the wrong resident. She immediately obtained the roommate’s vital signs, which showed blood pressure 90/50 mm Hg, heart rate 38 beats per minute, respirations 12, and oxygen saturation 98%, and contacted 911, the physician, and the resident representative. Emergency department documentation later confirmed that the resident arrived with accidental opiate poisoning and profound bradycardia, with reported heart rates as low as 29 beats per minute and low blood pressures, and required two doses of naloxone to stabilize heart rate and blood pressure before being discharged back to the facility the same day. Beyond this event, the facility’s systemic failure to maintain an effective resident identification system contributed to the deficiency. Observations showed that during medication administration, some residents did not have photographs in the electronic health record, even though the system had a designated location for such photos. Staff interviews confirmed that nurses relied primarily on electronic photographs to identify residents, but several residents lacked these photographs. Staff also reported using familiarity with residents, asking residents to state their names when cognitively intact, or relying on room nameplates, and they were unable to describe a consistent method for identifying cognitively impaired residents. Clinical record review identified multiple residents without photographs uploaded until surveyor inquiry, and staffing records showed that agency nurses comprised a portion of licensed staff, increasing the likelihood that unfamiliar staff would depend on incomplete identification tools. The DON confirmed the medication error, the reliance on photographs for identification, and that the admissions position previously responsible for uploading photographs had been eliminated, with no documented competency validation or specific training on resident identification procedures for the agency RN involved.
Plan Of Correction
Facility completed resident identification pictures in the electronic medical records for residents 48, 53, 65, 6, 7, 12, 59, 34, 23 on 4/9/2026. All resident photos uploaded and audited on same date. 2. Audit of all residents completed on 4/9/2026 to ensure photos of all residents were present in their medical chart for identification purposes. 3. Facility procedures for Medication Administration, Resident Admission Procedure and Orientation checklist for LPN/RN were reviewed and updated to reflect the taking of photographs of new residents upon admission and place in the electronic medical record for resident identification, completed on 4/9/2026. Residents received wrist bands on 4/13/2026 with exception of 5 residents who refused to have a wrist band as a secondary method of identification. Agency RN marked as a "do not return" to facility and agency was updated to mediation error on 4/7/2026. Education completed with facility licensed nurses on 4/9/2026 and ongoing on policies and procedures, resident identification, secondary identifications with use of wrist band, and 5 rights of medication administration. 4. New admission audits will be completed by the NHA/designee to ensure photo identification is uploaded to the EMR. QA committee notified of the IJ and abatement plan of correction. New admission audits for picture identification will continue daily X 2 months with results of audits to QA committee for review and alternative actions as required. DON/designee will audit nurses administering medications to ensure the 5 rights of medication pass are followed and all residents have accurate resident identification prior to medications administration is identified in 3 resident med passes, 3 X week for 4 weeks. 5. April 25, 2026
Removal Plan
- Identify residents who do not have photographs in the electronic health record.
- Take resident photographs and upload them to the electronic health record; photograph any residents not available immediately upon their return and upload promptly.
- Audit all residents’ electronic health records to verify photographs are present for identification purposes and review the system process for resident identification.
- Order wristbands for all residents containing the resident’s name and date of birth as a secondary identification method.
- Update resident photographs in the electronic health record as necessary and review them annually during resident care planning meetings by the Social Services Director or designee.
- Ensure resident photographs are taken on the day of admission and uploaded to the electronic health record, and apply a medical wristband with resident name and date of birth per the admission procedure.
- Provide education for LPNs and RNs on the five rights of medication administration and use of electronic health record photographs for resident identification, and make education on obtaining and uploading photographs available.
- Provide the agency staffing company a copy of the education materials to be completed by agency staff prior to accepting shifts and update the agency orientation packet to include the revised admission procedure and updated medication administration policy.
- Audit new admissions to ensure photographs are uploaded appropriately into the electronic health record.
- Conduct daily audits of photograph identification for new admissions for two months, and report results to the Quality Assurance Committee for review and alternative actions as required.
Penalty
Resources
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Failure to follow warfarin orders led to significant med errors for a cognitively intact resident with a mechanical heart valve and hx of cerebral infarction. MAR review showed missed doses in one month and incorrect dosing and omissions in another, and the DON confirmed the orders were not followed.
A resident with a seizure disorder did not receive the ordered bedtime phenytoin dose after admission because the order was not entered into the system, and the MARs reflected only the once-daily dose. The resident later had a seizure and was transferred to the hospital, where records documented status epilepticus, a subtherapeutic phenytoin level, and active infection. Interviews confirmed the missed order and that the resident had been receiving only one daily dose.
Two residents experienced significant medication errors. One resident with COPD and other chronic conditions did not receive ordered Lasix or a daily nasal spray during observed med pass, and the RN signed the meds as given despite omitting them. Another resident with diabetes did not receive ordered blood sugar checks and Humalog insulin on time; an LPN was hours late with the lunch check and dose, then tried to return close to dinner for another check, which the resident refused. The facility policy required meds to be given safely and within the prescribed time frames.
A facility medication pass failed when multiple residents on one hall did not receive ordered morning meds, including insulin, pain meds, seizure meds, anticoagulants, and BP meds. MARs lacked documentation of administration, some required blood glucose, BP, pulse, or weight checks were not completed, and residents reported pain, weakness, and concern about missed meds. The DON acknowledged the coverage issue and stated the missed 8 a.m. meds were significant medication errors.
A resident received 2.5 mL of Morphine Sulfate PO instead of the ordered 0.25 mL dose after a CNA/MA medication error. The resident then developed decreased O2 levels, lethargy, respiratory distress, and apnea, and required Narcan. The EMR lacked documentation of post-error assessments, call times to hospice or Ecare, an incident report, and a documented physician order for the Narcan given by hospice.
A resident with a BIMS score of 13 received oral sertraline solution without being diluted as required by the manufacturer. The MAR showed the medication was given, but the package instructions stated it must be mixed with 4 oz of approved liquid before use. After the dose, the resident complained of a burning tongue and sore throat, and staff and the NP confirmed the medication error.
Failure to Follow Warfarin Orders
Penalty
Summary
The facility failed to ensure that physician orders were followed for Resident 93, resulting in significant medication errors involving warfarin. Resident 93 was cognitively intact, received an anticoagulant, and had diagnoses including cerebral infarction and a mechanical heart valve requiring lifelong blood-thinning medication. A review of the resident’s MAR showed that warfarin ordered in December 2025 was not administered from December 18 through December 21, 2025. In addition, physician orders in May 2026 directed specific warfarin doses on alternating days, but the MAR showed that staff administered 7.5 mg on May 12 and May 14, and no warfarin was given on May 13 or May 15. The DON confirmed that a medication error occurred in December and that the warfarin orders were not followed in May 2026.
Missed Antiseizure Medication Order Led to Seizure Event
Penalty
Summary
The facility failed to ensure that a resident with a seizure disorder received physician-ordered phenytoin after admission. The resident’s hospital discharge orders reflected phenytoin oral suspension 25 mg/mL, 4 mL daily and 8 mL at bedtime, but the facility’s physician orders only reflected phenytoin oral suspension 100 mg/4 mL, 4 mL once daily. The March and April MARs showed administration of the once-daily dose, but did not reflect the ordered bedtime dose for 27 days. The resident had a history of unspecified convulsions and severe cognitive impairment, and the care plan identified seizure disorder with an intervention to give seizure medication as ordered by the doctor. The hospital record showed a phenytoin level of 21.43 mcg/mL before admission. The facility record also showed that the resident later had a seizure lasting approximately 4 minutes and was transferred to the hospital. The hospital record from the transfer documented status epilepticus, subtherapeutic phenytoin level of 2.4, and active infection including UTI/sepsis and possible pneumonia. In interviews, the LVN stated the resident received only one daily dose and that the bedtime Dilantin order had been missed when entered into the system. The DON stated the admitting nurse forgot to place the correct order and that the resident only received the once-daily dose because the bedtime dose was not entered.
Significant medication errors with missed ordered medications and delayed insulin coverage
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, affecting two residents reviewed for medication administration. Resident #73 had diagnoses including COPD, multiple sclerosis, hypertension, and peripheral vascular disease, and was noted to have impaired cognition on a Quarterly MDS assessment. His orders included Lasix 80 mg by mouth in the morning and fluticasone propionate nasal spray once daily for nasal congestion. During observed medication administration, an agency RN obtained his morning medications but omitted both the fluticasone propionate nasal spray and the Lasix tablet, then signed them off as administered. When interviewed afterward, the RN stated she had not given the nasal spray because she thought he usually refused it, but she had not offered it to him, and she stated she had missed the Lasix order. The resident stated he always took his nasal spray and that it was not given that morning. Resident #32 had diagnoses including diabetes, anemia, depression, and cellulitis, and was cognitively intact. Her orders required blood sugar checks before meals and at bedtime, with Humalog insulin given per sliding scale coverage. On 05/13/26, former LPN #649 documented a blood sugar of 256 at 7:00 A.M. with 8 units of Humalog given, and a blood sugar of 290 at 11:00 A.M. with 8 units of Humalog given, but the blood sugar summary showed the first documented blood sugar was at 8:30 A.M. and the next was not until 3:20 P.M., with no dinner blood sugar documented. The resident reported that the LPN did not check her breakfast or lunch blood sugar or give insulin when due, and that he later attempted to return close to dinner to check again and give another dose, which she refused because it was too close together. The former LPN acknowledged he was three to four hours late with the lunch blood sugar and insulin, said he got behind during the day, and confirmed he did not notify the DON or physician that the blood sugar and/or insulin was not administered on time.
Missed Morning Medications and Insulin Pass
Penalty
Summary
The facility failed to administer physician-ordered medications during the morning medication pass on 5/10/26, resulting in significant medication errors for eight residents on the 100 hall. The report states that R1, R2, R3, R4, R5, R6, R7, and R8 did not have nurses’ initials documented on their May 2026 MARs for multiple ordered medications that were due that morning. The missed medications included insulin, pain medications, antihypertensives, anticoagulants, anticonvulsants, diuretics, and other routine medications ordered for chronic conditions. R5, who had a BIMS score of 15 and no cognitive impairment, had ordered oxycodone/APAP for pain related to rheumatoid arthritis, osteoarthritis, and scoliosis, along with benazepril for hypertension. The pain assessment scheduled for 8:00 am was not documented as completed, and the MAR did not show the morning dose given. R5 stated she had extreme pain on Mother’s Day, rated it 10/10, and said she did not receive her pain medication when scheduled. The controlled substance proof of use sheet showed the oxycodone/APAP was not removed until the 12:00 pm dose, confirming no 8:00 am dose was administered. R1, R2, and R3 each had ordered insulin with meals and other routine medications, but no blood glucose checks were documented at the morning medication time to determine whether sliding-scale insulin was needed. R1’s first blood sugar check was not completed until after lunch and was 441 mg/dL; the MAR documented 12 units of insulin based on that later reading, and the record did not show provider notification for a blood glucose greater than 400. R2 and R3 also had multiple morning medications not documented as administered, including insulin and other chronic medications. R2 stated the morning was the worst because there was no nurse and she did not get insulin or an accu-check, and R3 had no documented blood glucose measurement to determine insulin dosing. R4, R6, R7, and R8 also had multiple morning medications not documented as given. R4’s missed medications included seizure medication, pregabalin, lamotrigine, and furosemide; R4 stated she was upset because she was supposed to take pain, seizure, and blood pressure medication. R6 had missed Norco, clopidogrel, torsemide, and eslicarbazepine, and also had no documented daily weight; she stated she did not get her medications and had significant leg pain. R7’s missed medications included tramadol, Eliquis, metoprolol, and losartan, with no corresponding blood pressure or pulse documented for the metoprolol hold parameters. R8’s missed medications included aspirin, amlodipine, metoprolol succinate, and torsemide, and the daily weight was not documented as completed. The DON acknowledged the medication errors occurred because of nurse coverage issues on the 100 hall, and the facility policy states medications are to be administered as prescribed with sufficient staff and a medication distribution system to ensure safe administration without unnecessary interruptions.
Significant morphine dosing error with respiratory depression
Penalty
Summary
The provider failed to ensure a resident was free from a significant medication error when a CNA/medication aide administered 2.5 mL of Morphine Sulfate orally instead of the ordered 0.25 mL dose. The resident had an order for Morphine Sulfate 100 mg/5 mL to be given as needed for pain or shortness of breath. The incorrect dose was 2.25 mL over the prescribed amount. After the incorrect dose was given, the resident developed decreased oxygen levels, lethargy, respiratory distress, and apnea. The resident required Narcan after the medication error. The record states that Ecare, the DON, hospice, and nursing staff were notified, and the resident was monitored after the event. The hospice RN later reported that the resident had shallow breathing with pauses up to 20 seconds and oxygen saturation dropping into the mid to lower 80s before Narcan was ordered. The resident's EMR did not document vital signs or assessments completed after the morphine error, and there was no documentation of the time calls were made to hospice or Ecare. There was also no incident report completed for the medication error, no physician's order documented for the Narcan given by hospice, and the verbal order for Narcan was not entered into the MAR with the ordering physician's name. The DON stated she expected a nursing assessment with respiratory rate, blood pressure, pulse, oxygen, temperature, and orientation or alertness documented after a narcotic medication error.
Undiluted Zoloft Oral Solution Administered
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when staff administered undiluted Sertraline Hydrochloride (Zoloft) oral solution. The resident was admitted after joint replacement surgery and had a BIMS score of 13, indicating cognitive intactness. The facility policy required medications to be administered according to the manufacturer’s specifications, including proper preparation and administration of the drug. The resident had an order for Sertraline HCl oral concentrate 20 mg/ml by mouth, and the MAR showed the medication was administered on the day of the incident. The medication package and prescribing information stated that Zoloft oral solution must be diluted before use and mixed with 4 ounces of water, ginger ale, lemon/lime soda, lemonade, or orange juice only. Despite these instructions, the medication was given without being mixed in liquid. After administration, the resident complained of a burning tongue and sore throat, and the incident was documented as liquid Zoloft not mixed in liquid. The resident’s representative reported that the resident said her throat was burning because the nurse did not mix the medication, and the resident was taken to the emergency room for evaluation and then home. Interviews with nursing staff and the NP confirmed the medication had been administered without dilution and that the resident experienced mouth and throat discomfort afterward.
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