Failure to Prevent Significant Medication Errors for Two Residents
Summary
The deficiency involves the facility’s failure to prevent significant medication errors for two residents during medication administration. For the first resident, who had multiple complex diagnoses including pneumonia, COPD, CHF, atrial fibrillation, pulmonary hypertension, peripheral vascular disease, chronic kidney disease stage 3, hypertension, hyperlipidemia, and aortic valve stenosis, a nurse on her first day at the facility administered another resident’s medications in error. The resident was cognitively intact and receiving numerous scheduled medications, including diuretics, anticoagulants, antihypertensives, electrolyte replacements, and oxygen. A Medication Error Report documented that the resident was mistakenly given four incorrect medications intended for another resident, including a blood sugar–lowering medication, an antidepressant, a uric acid–lowering medication, and an antihypertensive with side effects of hypotension and hyperkalemia and label warnings related to diabetic medications. The error for the first resident occurred when an LPN, new to LTC and to the facility’s computer system, misidentified the resident and pulled the wrong medications. The LPN reported that it was her first day, she had limited orientation time with an RN preceptor that morning, and she had not been checked off as competent to administer medications independently. She stated she did not yet know the residents, found the electronic photos too small to distinguish individuals, and did not know how to enter orders into the computer. She described feeling overstimulated and attempting to work independently. The UM, who was simultaneously functioning as wound nurse, UM, and preceptor, left the LPN alone on the cart after the LPN stated she felt comfortable, despite the UM not having observed her passing medications and not having completed the medication portion of the competency checklist. The RN who precepted earlier in the day stated the LPN had only observed her, had not performed tasks independently, and had not been checked off to administer medications alone. Following the wrong-medication administration to the first resident, vital signs later showed hypotension and hypoglycemia, and the resident was sent to the hospital. Hospital records documented treatment for a medication error, hypotension, hypoglycemia, elevated heart enzymes, and acute kidney injury, with very low blood pressure on arrival and the resident reporting feeling like they were dying. Documentation from the hospital indicated facility staff reported the resident had been hypotensive for two hours. The pharmacist, after reviewing the resident’s scheduled medications and the medications given in error, stated she would have monitored for low blood pressure, low blood sugar, and oversedation, and identified multiple medications that could contribute to these effects. The NP stated it was difficult to determine whether the medication error caused the event, noting the resident’s existing pneumonia and kidney function issues. The resident’s representative reported being notified of a severe drop in blood pressure and stated that a physician advised seeking legal advice. The second resident involved in the deficiency had multiple diagnoses including critical illness myopathy, metabolic encephalopathy, cerebral edema, diabetes, morbid obesity, respiratory failure with hypoxia and hypercapnia, obstructive sleep apnea, cognitive communication deficit, dysphagia, hyperlipidemia, bipolar disorder, hypertension, and chronic kidney disease, and was cognitively intact. This resident was on a complex medication regimen including antipsychotics, antidepressants, anticoagulants, antibiotics, diuretics, opioids, and hypoglycemics. A Medication Error Report documented that the resident was accidentally given two sleeping pills instead of two pain pills. The error occurred while an LPN in training and her preceptor were both pulling medications from the same cart, with the trainee pulling non-controlled medications and the preceptor pulling narcotics. For the second resident, the trainee LPN reported that the resident had requested a pain pill but was given sleeping pills instead. She stated that the mistake was discovered later when controlled medications were counted and that the sleeping pill, a controlled medication, was stored in the narcotic box with other controlled medications. She reported that the preceptor punched the medication from the wrong card, that the pills were both small white tablets, and that they were trying to hurry. The trainee LPN stated she did not recall any specific competency check-offs and that her license had simply been verified. The pharmacist stated that the dose of sleeping medication given exceeded the recommended daily dose and would definitely increase sedation, with potential for amnesia, CNS depression, and breathing interruptions if the resident did not use a pressurized mask while sleeping, as well as possible sleepwalking episodes. The NP later reported there were no adverse side effects observed in this resident. The facility’s written Medication Administration policy required that medications be administered in accordance with orders, that the individual administering medications verify resident identity before administration, and that the label be checked three times to ensure the right resident, medication, dose, and route. The policy also stated that medications ordered for one resident may not be administered to another, and that new personnel authorized to administer medications would not be permitted to prepare or administer medications until oriented to the facility’s medication administration system. It further required that a charge nurse accompany new nursing personnel on medication rounds for a minimum of three days to ensure procedures were followed and proper resident identification methods were learned. Interviews with the UM, RN preceptor, and LPNs indicated that the new nurses involved in both medication errors were allowed to participate in or conduct medication passes without full completion of competency checklists, without consistent direct observation, and while preceptors were performing multiple roles or sharing the cart, contributing to the misadministration of medications to both residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to ensure residents were free from significant medication errors when one resident drank coffee containing another resident’s medications. The DON stated medications should always be observed during administration, but a CMA said they did not watch the resident take the meds and gave them in coffee without observing the resident drink it. The physician was notified and reviewed the medications involved.
Unattended Medication Left at Resident Bedside: A resident with severe cognitive impairment had a medication cup containing four tablets left unattended on the bedside table. An LPN stated she placed the medications there while getting juice and admitted this was against facility policy. RN and DON confirmed medications should not be left unattended at the bedside and that the action violated the facility’s medication administration P&P.
Missed Hydroxyurea Doses on Admission: A resident with thrombocytopenia, chronic myeloproliferative disease, and CML did not receive ordered Hydroxyurea on admission. The hospital discharge order called for Hydroxyurea 500 mg every other day, but the med was not entered promptly, pharmacy delivery was delayed, and the MAR showed the first documented dose was not given until several days later. The family member reported the resident missed his chemotherapy med for three days, and staff interviews showed uncertainty about who completed the admission med review and when the order was obtained.
Medication Error Caused Severe Bradycardia and Hospital Transfer: A severely cognitively impaired resident with sinus bradycardia received his scheduled AM meds and then was mistakenly given another resident's meds, including metoprolol succinate ER, amlodipine, tamsulosin, and donepezil. He became lethargic with HR in the 30s to 40s and BP 90/60, was sent to the hospital, and was diagnosed with severe symptomatic bradycardia, hypotension, and progression to complete heart block requiring epinephrine, atropine, and a dual-chamber pacemaker.
Missed Antiseizure Medication Doses: A resident with epilepsy and other significant diagnoses did not receive ordered Phenytoin doses because the bubble pack was empty and the medication was unavailable in the cart. An LPN reported missed doses, another LPN said she faxed the pharmacy more than once but did not follow up, and the DON acknowledged 19 missed doses. The pharmacist said only a 3-day supply had been delivered and the facility had not provided required physician clarification before the refill was issued. The resident later had seizure activity and was transferred to the hospital for further evaluation.
A facility failed to administer multiple ordered medications for three residents. One resident with seizure disorder, hypotension, and colon cancer missed repeated doses of seizure meds, midodrine, Depakote, and an antibiotic; a second resident with seizure disorder, diabetes, and HTN missed repeated doses of lamotrigine, levetiracetam ER, and pregabalin; and a third resident with diabetes and cellulitis missed ordered sliding-scale insulin doses, with blood glucose not monitored at the missed times. An LVN stated meds should be given as ordered, and the ADON and pharmacy consultant acknowledged the missed administrations.
Medication Administration Error
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for 1 of 5 sampled residents reviewed for medication administration. A policy stated medications are to be administered at the time they are prepared and the resident is to be observed taking them. The record showed that one resident drank coffee containing medications that belonged to another resident, and the medication administration record showed that the other resident received Rexulti 2 mg, buspirone HCl 10 mg, and alprazolam 0.5 mg. The DON stated medications should always be observed during administration to ensure the resident takes all of the medication and to prevent another resident from taking them. CMA #2 stated they did not watch the resident take the medications and gave the medications in coffee without observing the resident drink it. The physician stated they were notified that one resident had taken medications belonging to another resident and ordered the evening medications held, vital signs monitored, and assessments completed.
Unattended Medication Left at Resident Bedside
Penalty
Summary
The facility failed to ensure medications were secured and administered according to its medication administration policy for one sampled resident. Resident 3 had diagnoses including encephalopathy and senile degeneration of the brain, and the MDS dated May 6, 2026, showed a BIMS score of 00, indicating severe cognitive impairment. During observation on July 2, 2026, a medication cup containing four tablets was found unattended on Resident 3’s bedside table in the resident’s room. When asked, Resident 3 stated she did not know whether the medication belonged to her and appeared confused. During the same observation, RN 1 confirmed the four tablets were left unattended on the bedside table and stated that it was against facility protocol to leave medication unattended at the bedside. RN 1 stated the medications likely had been left there by LVN 1 and should have remained under LVN 1’s direct supervision until administered. LVN 1 stated the tablets belonged to Resident 3 and admitted she had placed them on the bedside table while she went to obtain juice for the resident, acknowledging that leaving the medications unattended was a mistake and was not consistent with the facility’s medication administration policy. The DON reviewed the policy, which stated that medications are to remain secured when the medication nurse or aide is out of sight, and confirmed that leaving medications unattended on a bedside table violated facility policy and the expected standard of practice.
Missed Hydroxyurea Doses on Admission
Penalty
Summary
The facility failed to ensure that a resident with thrombocytopenia, chronic myeloproliferative disease, and chronic myeloid leukemia received Hydroxyurea as ordered upon admission. The resident was admitted with a hospital discharge instruction to start Hydroxyurea 500 mg, 1 capsule by mouth every other day, beginning on 4/24/26. A physician progress note on 4/24/26 documented that the resident was taking Hydroxyurea 500 mg once daily and stated that the medication list was reviewed and reconciled with the patient. The resident’s medication order was not entered into the facility’s order summary until 4/27/26, when a physician order for Hydroxyurea 500 mg every 48 hours was documented. That same evening, an RN documented that the oncologist called with the order, noted the order was already in place, and recorded that pharmacy was called to deliver the medication. The RN also documented that the resident’s family member said she could go to her pharmacy to get the medication, then later documented that the pharmacy reported the Hydroxyurea would be delivered that night and that the family member could not obtain it from the pharmacy. The MAR showed the resident received Hydroxyurea 500 mg by mouth on 4/29/26, and documentation indicated the medication was not administered on 4/27/26. In a telephone interview, the family member stated the resident missed his chemotherapy medication for three days while in the facility and that they gave him the medication after bringing the issue to staff’s attention. Interviews with nursing and administrative staff indicated uncertainty about who completed the medication review on admission and that the facility expected family members to bring chemotherapy medications from home, with the medication not being ordered from the pharmacy until after the oncologist was contacted.
Medication Error Resulted in Severe Bradycardia and Hospitalization
Penalty
Summary
The facility failed to prevent a significant medication error involving a severely cognitively impaired resident with diagnoses including Alzheimer's disease, sinus bradycardia, hypertension, diabetes, depression, and psychotic disorder with hallucinations. On the morning of the event, a Medication Aide administered the resident's scheduled medications, which included propranolol ER, quetiapine, donepezil, metformin ER, and citalopram. The aide then returned to the medication cart, prepared another resident's medications, and later gave those medications to the same resident in error. The medications mistakenly given to the resident included metoprolol succinate ER, tamsulosin, amlodipine, and donepezil, which were prescribed for another resident. Approximately 30 minutes later, the Medication Aide realized the error and reported it to the nurse. The resident was assessed and found to be lethargic with a heart rate in the 40s that dropped into the high 30s and a blood pressure of 90/60. EMS was contacted and transported the resident to the hospital for evaluation. Hospital records documented severe symptomatic bradycardia and hypotension secondary to an unintentional medication overdose with beta blockers and amlodipine. The resident's ECG progressed from sinus bradycardia with second-degree AV block to complete heart block, and he required epinephrine infusion and atropine with limited response. He later underwent implantation of a dual-chamber pacemaker and returned to the facility after hospitalization. Interviews with the Medication Aide, nurse, NP, pharmacist, and Medical Director confirmed that the resident received both his own morning medications and another resident's medications, and that the medication error was associated with the resident's decline in heart rate and blood pressure.
Missed Antiseizure Medication Doses
Penalty
Summary
The facility failed to ensure that a resident with diagnoses including epilepsy, hemiplegia, hemiparesis, and hypertension received Phenytoin as ordered. The physician’s order required Phenytoin 100 mg by mouth at 9:00 AM, 1:00 PM, and 5:00 PM for seizures, but the Medication Administration Record showed multiple missed doses from June 7 through June 17, 2026, totaling 19 doses. During interview, an LVN stated one dose was not given because the bubble pack was empty, and another LVN stated the medication was not in the bubble pack for a couple of days and that she faxed the order to the pharmacy more than once because the medication was not available in the medication cart. The DON reviewed the MAR and acknowledged the medication was not administered for eight days, totaling 19 doses, and stated medications must be available for residents and that the pharmacy is contacted immediately when they are not. The pharmacist stated only a three-day supply had been delivered and that the facility did not provide required clarification from the physician before June 18, 2026, so the pharmacy did not issue a refill until that date. The resident’s clinical record also documented seizure activity on June 17, 2026, with two petite mal seizures and a blood pressure of 162/111, after which the physician ordered transfer to the hospital for further evaluation.
Repeated Missed Medication Administrations
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for three sampled residents. Resident 1 had diagnoses including colon cancer, muscle weakness, seizure disorder, and hypotension, and the MDS indicated the resident’s cognition was not intact and the resident was unable to make decisions. The physician orders included Keppra, lacosamide, Depakote, midodrine, and metronidazole, but the MAR showed multiple missed doses of each medication across May 2026, including repeated missed evening doses of seizure medications, missed midodrine doses, missed Depakote doses, and missed metronidazole doses. Resident 2 had diagnoses including muscle weakness, seizure disorder, hypertension, diabetes, and a history of falls, and the MDS indicated cognition was intact. The physician orders included lamotrigine, levetiracetam ER, and pregabalin, but the MAR showed multiple missed doses of all three medications in May and June 2026. The missed doses included repeated omissions of the seizure medications and pregabalin at scheduled administration times. Resident 3 had diagnoses including cellulitis of both lower limbs, diabetes, and hypertension, and the MDS indicated cognition was intact. The physician order included insulin aspart by sliding scale before meals and at bedtime, but the MAR showed that blood glucose was not monitored and the insulin order was not administered on multiple occasions in June 2026. During interviews, an LVN stated medications should be administered as ordered, and the ADON acknowledged that the residents had multiple medications not administered as ordered. The pharmacy consultant stated antibiotics should be given as scheduled and completed, missing seizure medications increase the chance of seizure episodes, and the facility should follow physician orders for medication administration.
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