Failure to Ensure Accurate and Timely Medication Administration for Antihypertensives and Anticoagulant
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow its own medication administration policies, particularly regarding timeliness, accuracy of orders, and documentation. One resident (R3), who has diagnoses including heart failure, hypertensive heart disease, type 2 diabetes mellitus, end stage renal disease with dependence on dialysis, and obesity, and who is cognitively intact with a BIMS score of 14, reported frequently receiving medications late and stated that on the day of observation the resident had not received any medications despite returning from dialysis at 10:30 AM. At 12:17 PM, an RN (V18) assessed R3’s blood pressure at 147/89 with a heart rate of 100 and acknowledged to the resident that the blood pressure was high because medications were being given late, specifically referencing the resident’s beta blocker and hypertension medications. At approximately 12:24 PM, V18 prepared R3’s morning medications, including nifedipine ER 60 mg, metoprolol tartrate 12.5 mg, gabapentin 100 mg, sevelamer 800 mg, and calcitriol 0.5 mcg, and stated these medications should have been given around 9:00 AM but were late. At 12:30 PM, V18 administered the medications to R3 and told the resident that medications were not supposed to be given outside the one-hour before/after window, describing this as a legal requirement, but proceeded with administration due to the elevated blood pressure. V18 further explained that the facility’s procedure is to check vital signs and then administer medications, and admitted that R3’s medications should have been given as soon as possible after returning from dialysis at 10:30 AM. V18 stated that the medications were not given timely because the nurse was responsible for 27–30 residents and acknowledged having given R3’s medications late on prior occasions, describing it as difficult to complete medication passes on time. The consultant pharmacist (V16) confirmed that nifedipine and metoprolol were being used to treat blood pressure and stated that if these medications are not received, blood pressure is expected to increase, emphasizing that nifedipine ER should be given at the same time every day. Upon reviewing R3’s record, V16 found no documentation of when the previous evening’s metoprolol dose was given and could not determine whether it had been administered, noting that nurses should document all administrations or refusals. The DON (V2) confirmed that facility policy allows a one-hour before and after window for medication administration and that medications for residents on dialysis should be scheduled so they can be administered at the same time every day, with nurses expected to notify the provider if scheduled times conflict with dialysis. V2 verified that R3’s nifedipine and metoprolol were scheduled for 9:00 AM, during dialysis chair time, and that R3 had not been consistently receiving these medications at the ordered times. V2 stated that V18 could have administered the medications closer to the scheduled time and confirmed there was no documentation that the 6:00 PM metoprolol dose was given on 4/12/2026. Review of R3’s Medication Administration Audit Report showed multiple late administrations of metoprolol and nifedipine on various dates, as well as missing documentation for certain metoprolol doses. R3’s progress notes contained only one entry indicating the resident requested morning medications after dialysis, with no further documentation explaining late administrations or provider notification about late or missed doses. These practices conflicted with facility policies requiring medications to be administered within 60 minutes of the scheduled time, accurate documentation of administration or refusal, and explanatory notes when doses are withheld, refused, or given at times other than scheduled. A second resident (R2), admitted with diagnoses including type 2 diabetes, hypertension, schizophrenia, atrial fibrillation, chronic right heart failure, and a left below-knee amputation, and cognitively intact with a BIMS score of 13, reported that nurses had R2’s medication doses and times wrong and that medications were often passed late or not given at all. Hospital discharge documentation for R2 listed Eliquis 5 mg to be taken orally twice daily, but R2’s March MAR showed an order for Eliquis 5 mg once daily starting shortly after admission, and R2 received the medication only once daily for eight days. The MAR later reflected a corrected order for Eliquis 5 mg twice daily. A progress note documented that pharmacy contacted the facility on 3/10/26 stating Eliquis is always given twice daily and that the MD needed to correct the order; the nurse noted reaching out to the provider but receiving no response at that time. The consultant pharmacist confirmed that Eliquis is never given once daily, that manufacturer recommendations are for twice-daily dosing, and that once-daily dosing for atrial fibrillation management could lead to irregular heart rate or increased risk for clots. The DON stated that the admitting nurse entered the Eliquis order incorrectly, that Eliquis is supposed to be given BID, and that R2 received the wrong Eliquis dose for a few days. Facility policies titled “Guidelines For Physician Orders (Following Physician Orders)” and “Section 5.0 Medication Administration” require that physician orders be accurately implemented and followed, that two nurses review admission and readmission orders as a double check, and that medications be administered as prescribed and within 60 minutes of the scheduled time. These policies also require that unusual doses or orders that appear inconsistent with a resident’s diagnosis be clarified with the physician prior to administration, that the MAR be initialed for each dose given, and that any withheld, refused, or off-schedule doses be circled and explained in the record, with physician notification if two consecutive doses are withheld or refused. The observed late, inconsistent, and undocumented administration of antihypertensive medications for R3, the lack of timely rescheduling or provider notification related to dialysis conflicts, and the incorrect once-daily Eliquis order and administration for R2, despite pharmacy input and existing policies, collectively demonstrate the facility’s failure to ensure residents were free from significant medication errors and to adhere to its own medication administration procedures.
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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