High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. 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: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Medication error rate exceeded the required threshold when an RN administered Amlodipine and Losartan Potassium to a resident despite a pulse below the ordered hold parameter of 60. The resident had HTN, hypotension, Parkinsonism, and moderate cognitive impairment. The RN acknowledged the error, and the DON and ADM stated they were unaware the physician orders had not been followed until after the observation.
Medication Administration Errors Exceeded Allowed Rate: The facility had a 5% med error rate based on 2 errors in 40 opportunities. During observation, an MA gave one resident guaifenesin 400 mg instead of the ordered 600 mg dose, and gave another resident cranberry 450 mg instead of the ordered 500 mg dose. The MA stated she caught one error but missed the other, while the DON said he was unsure when staff last received med admin training and the ADM expected staff to verify the correct dose before giving meds.
An LPN administered nine oral medications to a resident 1 hour and 36 minutes late, despite provider orders specifying an 8:00 AM administration time. Surveyors found nine errors in 31 medication administration opportunities, and the DON stated the expected medication window was 1 hour before and 1 hour after the ordered time.
Medication administration error rates exceeded the allowed threshold when an MA gave scheduled meds to two residents after the ordered 9:00 a.m. time. One resident had dementia, HTN, atherosclerosis, and clotting-related diagnoses and received acetaminophen, warfarin, atenolol, and enalapril late; another resident with HTN, depression, anxiety, and chronic pain received amlodipine, duloxetine, gabapentin, and Gemtesa late. Staff interviews confirmed expectations for timely administration, and the facility policy reviewed did not include a specific medication-time policy.
Medication Error Rate Exceeded Allowed Threshold: An LPN prepared and nearly administered two incorrect medications for a resident, including a BP medication without checking the resident’s BP despite a hold parameter and Meclizine at 25 mg instead of the ordered 12.5 mg. The survey found the facility’s medication error rate was 8% (2 errors out of 25 opportunities), exceeding the required rate of less than 5%.
Medication error rate exceeded the allowed threshold after surveyors found 3 errors in 25 opportunities. An RN gave insulin at an inappropriate site for a resident with DM and severe cognitive impairment, and a Med Aide failed to administer ordered eye drops and did not give the full ordered dose of a laxative for another resident with severe cognitive impairment. The DON stated staff were expected to audit and replenish carts and notify nursing if OTC meds were needed.
Medication Given Outside Ordered Vital Sign Parameters
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent. Surveyors found an 8 percent medication error rate based on 2 errors out of 25 opportunities, involving 1 of 3 residents reviewed for medication administration. The deficiency centered on Resident #81, an [AGE]-year-old female admitted on 03/06/2026 with diagnoses including hypotension, candidiasis, essential primary hypertension, Parkinsonism, and cognitive communication deficit. Her quarterly MDS dated 06/09/2026 showed a BIMS score of 08, indicating moderate cognitive impairment. Resident #81 had physician orders for Amlodipine 5 mg daily and Losartan Potassium 50 mg twice daily, both with instructions to hold if pulse was less than 60. During a medication administration observation, RN A checked the resident’s vital signs before giving the medications and obtained a blood pressure of 129/65 and a pulse of 57. Despite the pulse being below the ordered parameter, RN A administered both Amlodipine and Losartan Potassium and then documented the medications as given on the MAR. During interview, RN A stated the resident should not have received either medication because the pulse was below the ordered parameter and acknowledged that she made an error and did not realize the pulse was below the set parameters at the time of administration. The DON and ADM stated they were not aware the orders had not been followed until after the observation and confirmed that nursing administration was responsible for ensuring medications were given according to physician orders. The facility policy stated medications are to be administered in accordance with prescriber orders and that vital signs are checked and verified when necessary before administration.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate was less than 5 percent. Based on observation, interview, and record review, the facility had a medication error rate of 5% based on 2 out of 40 opportunities for 2 of 4 residents reviewed for medication administration. The errors involved MA G giving Resident #56 guaifenesin 400 mg instead of the ordered Mucinex oral tablet extended release 12 hour 600 mg, and giving Resident #47 cranberry 450 mg instead of the ordered cranberry soft oral tablet chewable 500 mg. Resident #56 was a [AGE] year-old male admitted and readmitted with diagnoses including acute respiratory failure, protein-calorie malnutrition, and quadriplegia, and had a physician order for guaifenesin 600 mg once daily for cough. During medication administration observation, MA G dispensed guaifenesin 400 mg to the resident. Resident #47 was a [AGE] year-old male admitted and readmitted with diagnoses including acute respiratory failure, immunodeficiency, and neuromuscular dysfunction of bladder, and had an order for cranberry 500 mg twice daily related to neuromuscular dysfunction of bladder. During observation, MA G dispensed cranberry 450 mg to the resident. MA G stated she caught the error for Resident #56 and another nurse obtained the correct dose, but she did not notice the wrong dose for Resident #47 and stated it was her fault. The DON stated he was unsure when staff last received medication administration training and was not aware of such training during his time as DON. The ADM stated staff were expected to verify the correct dose before giving medications.
Medication Administration Timing Error Exceeded Allowed Error Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent. During observation, interview, and record review, surveyors found that Staff J, an LPN, prepared and administered nine oral medications to Resident 96 at 9:36 AM even though the provider’s orders for June 2026 specified that the medications were to be given at 8:00 AM. The medications were administered one hour and 36 minutes late, and this accounted for nine errors in 31 opportunities during medication administration for 1 of 6 sampled residents reviewed for medication administration. During interview, Staff J stated nurses had up to two hours to administer medications after the ordered time, while the DON stated the medication administration time was one hour before and one hour after the specific time of the order and that the nurse’s practice did not meet expectations.
Medication Administration Times Not Followed
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5 percent. Surveyors observed a medication error rate of 32% based on 8 errors out of 25 opportunities, involving two residents and one medication aide during medication administration observations. The errors involved medications being administered outside the scheduled administration window for two residents. Resident #2 was an older male admitted with diagnoses including unspecified dementia, hypertensive heart disease, atherosclerosis of the aorta, and embolism and thrombosis of arteries of the extremities. His medication orders included acetaminophen, warfarin, atenolol, and enalapril, with scheduled administration times of 9:00 a.m. During observation, MA A began preparing and then administered Resident #2's medications at 10:30 a.m. to 10:36 a.m., after the scheduled time shown on the eMAR. MA A stated the medications were due at 9:00 a.m. and said she did not get there until 9:00 a.m. Resident #3 was an older female admitted with diagnoses including hypertensive heart disease, major depressive disorder, anxiety, and chronic joint pain. Her orders included amlodipine, duloxetine, gabapentin, and Gemtesa, with scheduled administration times of 9:00 a.m. for the daily medications and 9:00 a.m., 1:00 p.m., and 5:00 p.m. for gabapentin. During observation, MA A prepared and administered Resident #3's medications at 10:36 a.m. to 10:40 a.m., after the scheduled 9:00 a.m. time shown on the eMAR. Interviews with LVN C, LVN B, and the DON reflected that staff were trained on medication administration times and that medications should generally be given within one hour before or after the scheduled time, with notification to the MD, DON, ADON, and family if given late. The facility's policy titled Administering Oral Medications did not include a specific policy regarding medication administration times, and the referenced Administering Medications policy was not available.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with a documented error rate of 8% based on 2 errors out of 25 opportunities. During a medication administration observation with an LPN, Resident #81’s medications were prepared using the electronic medical record, and the nurse retrieved one Olmesartan/amlodipine/hydrochlorothiazide 40/10/25 mg tablet and one Meclizine 25 mg tablet and placed them in a medication cup. The nurse entered the resident’s room and placed the cup on the resident’s table, stating, “here’s your medication,” before the surveyor intervened and directed review of the physician orders. Review of the resident’s orders showed the Olmesartan/amlodipine/hydrochlorothiazide order included instructions to hold the medication if systolic blood pressure was less than 100, but the nurse had not checked the resident’s blood pressure before administration. The orders also showed Meclizine was prescribed at 12.5 mg, not the 25 mg tablet the nurse had prepared. In interview, the LPN confirmed she was prepared to administer the medications as set up, was unaware of the resident’s blood pressure status, and confirmed the Meclizine dose was incorrect. The unit manager stated medications were expected to be administered according to physician orders, with required vital signs obtained and medication dosage checked before administration. The resident’s care plan identified the resident as at risk for fluctuation in blood pressure and directed staff to administer medications as directed.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure that its medication error rate was not 5 percent or greater. Surveyors identified 3 medication errors out of 25 opportunities, resulting in a 12.0% error rate during medication administration observations for two residents. The report states that these failures could place residents at risk for incomplete therapeutic outcomes and decline in health. For one resident with Type 2 DM with hyperglycemia, cerebral infarction, heart failure, and severe cognitive impairment, RN A administered Novolog insulin at the resident’s deltoid area after the resident exposed her right arm, even though RN A stated insulin should be injected into fatty tissue in a subcutaneous area. The resident’s blood glucose was 255, and RN A had prepared both Novolog and Toujeo before entering the room. RN A stated she automatically gave the Novolog on the arm because the resident wanted it there. For another resident with constipation, essential hypertension, cerebral infarction, and severe cognitive impairment, MA A administered several oral medications but did not give the ordered artificial tears because they were not in the cart. MA A said she would get the medication from central supplies, went to an unidentified door, and then returned and signed off the EMAR after no one answered. Medication reconciliation later identified that the resident was also supposed to receive 2 tablets of Sennosides, and the DON stated staff were expected to audit and replenish carts and notify the nurse or unit manager if OTC medications were needed.
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