Widespread Medication Administration Errors and Omissions Involving High‑Risk Drugs
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with physician orders, timeframes, and documentation requirements for multiple residents, including those receiving high‑risk medications. Facility policies required medications to be given safely, timely, and as ordered, with immediate documentation and recorded reasons for any omitted doses. However, record review, MARs, narcotic count sheets, and EHR medication administration audits showed repeated omissions, late administrations, duplicate dosing, and missing documentation, without evidence that medical providers were notified when medications were not given or were given outside ordered timeframes. One cognitively intact resident with heart disease, diabetes, and a left lower leg amputation had two active oxycodone orders at the same time and received doses from both, resulting in excess administration of a controlled substance, including additional doses given as close as three hours apart. This resident also had numerous missed oxycodone doses, frequent late or missed blood glucose checks and lispro insulin administrations, and two dates where evening medications, including duloxetine, propranolol, blood glucose monitoring with lispro insulin, Lantus, acetaminophen, gabapentin, Symbicort, tamsulosin, melatonin, and ipratropium‑albuterol, were not documented as given. EHR audits showed over 400 instances of medications given more than one hour late, and narcotic count sheets had multiple missing entries over several months. The resident reported that medications were frequently not administered as scheduled and that morning medications were sometimes received after mid‑afternoon. Other residents experienced similar failures. One cognitively intact resident with diabetes, heart failure, and respiratory failure had multiple blank MAR entries indicating missed evening and morning medications, including blood glucose monitoring with insulin aspart, insulin glargine, Lovenox, duloxetine, metoprolol, torsemide, melatonin, and trazodone, and had over 700 occurrences of medications administered more than one hour late; this resident reported inconsistent medication administration and delays, including morning medications received after early afternoon and blood glucose checks and insulin not completed before meals. A resident with a seizure disorder, recent seizures, diabetes, and prior CVA had numerous missed morning and evening doses of anti‑seizure and anticoagulant medications, along with over 300 late administrations. Another cognitively intact resident with osteomyelitis, toe amputation, and hypertension had multiple missed evening doses of an ordered antibiotic, missed doses of hydralazine, and a date where evening doses of carvedilol, torsemide, and gabapentin were not documented as given. The nurse practitioner, PA, medical director, and administrator all acknowledged that medications must be administered as ordered, that residents had reported not receiving medications as prescribed, that providers were not consistently notified of omissions or late administrations, and that nurses were not always able to administer medications within expected timeframes. Across these residents, facility records consistently lacked documentation that medical providers were notified when medications were omitted or administered outside ordered timeframes. Medication administration audits from the EHR showed hundreds of late administrations for several residents, and MARs contained numerous blank entries indicating omitted doses of critical medications such as insulin, anticoagulants, anti‑seizure drugs, cardiac medications, antibiotics, and controlled pain medications. The medical director stated that if residents do not receive prescribed medications they could die and that the facility was potentially causing harm. The administrator confirmed awareness of residents not receiving medications based on reports from residents, families, staff, internal audits, and corporate oversight, and acknowledged that residents should receive medications as prescribed and that nurses should notify supervisors and providers when medications are omitted or given outside ordered timeframes.
Penalty
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Two residents experienced significant medication errors when ordered ATB therapy was not initiated or administered as prescribed. One resident with C-diff was discharged from the hospital on fidaxomicin twice daily, but multiple doses were missed after admission because the drug was not covered and considered too expensive, and the PCP was not documented as being notified until the family raised concerns and requested ER transfer. Another resident evaluated for sinus symptoms had Augmentin ordered twice daily by an NP, but staff did not recognize the order from the progress note, and weekend agency nurses did not access the emergency medication box or contact pharmacy, resulting in a two-day delay before the first dose was given, despite the facility’s policy requiring timely medication administration.
A resident with type 2 DM and chronic kidney disease, care planned for risk of hyper/hypoglycemia, had a physician order for 2 units of NovoLog via FlexPen to be given SQ before meals with a hold parameter for blood sugar below 70. During a medication pass, an LPN attached a needle to the insulin pen, dialed 2 units, and administered the insulin after the resident had finished breakfast, without priming the pen as required by the manufacturer’s instructions. The LPN stated she no longer primed pens because she had previously broken them while attempting to do so. The DON indicated pens were to be primed before each use, and review of the insulin pen instructions confirmed a 2-unit safety test (priming) was required before every injection. Review of the MAR also showed that routine blood glucose results were not documented, despite the resident receiving daily insulin.
The facility failed to ensure medications were administered as ordered when two residents did not receive multiple doses of their prescribed controlled medications due to reported unavailability, despite backup stock being present in the medication dispensing systems. One resident with anxiety and depression missed two scheduled doses of Ativan and became visibly distressed, shaking and tearful, while an LPN confirmed the omissions and the DON later acknowledged that Ativan tablets were available in backup stock. Another resident with a seizure disorder missed several scheduled doses of Phenobarbital after one dose was only partially available and subsequent doses were documented as unavailable and on order, even though the DON confirmed Phenobarbital tablets were present in the override cabinet. These events occurred despite facility policies requiring timely administration of medications as prescribed and advance reordering of controlled substances.
A resident with multiple serious diagnoses, including multiple myeloma and secondary malignant neoplasm of bone, had a physician order for Pomalyst 2 mg PO each morning, but the MAR showed two missed morning doses. Nursing notes documented that the drug was reportedly not available in the med cart, while an RN later stated the family had supplied the medication, it was placed in the top drawer of the cart, and the MAR reflected that location. The RN confirmed the resident did not receive the ordered doses, and no medication error report was completed despite the missed administrations and the facility’s policy requiring accurate medication administration per physician orders.
A resident with C. diff was admitted on an ongoing regimen of oral Vancomycin 125 mg every six hours, but the facility failed to administer four scheduled doses because the medication was not available. Nursing staff documented the missed doses on the MAR, yet there was no evidence the physician was notified of the unavailability. The first dose from the facility was not given until the evening of the second day after admission, and the Regional Nurse Consultant confirmed that Vancomycin was not in the starter kit, the pharmacy was not contacted until the following day, and multiple doses were missed.
A resident with chronic kidney disease and intact cognition had multiple ordered medications, including Buspirone, Ferrous Sulfate, Metoprolol, Lactulose, Xifaxan, and Humalog insulin with breakfast, as well as ordered blood glucose checks before breakfast and dinner. On a survey day, the resident returned from dialysis, ate breakfast, and remained on a transport cart awaiting transfer, while an LPN reported having fallen behind and not giving the scheduled morning medications when due. The resident stated that medications were consistently late and confirmed not receiving morning medications or insulin with breakfast that day. Review of MARs/TARs and confirmation by a regional RN showed that the resident’s scheduled medications, including insulin, were not administered timely and that ordered blood glucose checks for breakfast and dinner were not obtained, contrary to the facility’s medication administration policy.
Delayed and Missed Antibiotic Therapy for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors by not providing ordered antibiotic (ATB) therapy in a timely manner and as prescribed. One resident with enterocolitis due to Clostridium difficile (C-diff), hypertension, malignant neoplasm of the prostate, and chronic kidney disease was admitted with a hospital discharge order for fidaxomicin 200 mg by mouth every morning and at bedtime for five days. The last hospital dose was given on the morning of admission, but the facility’s MAR showed that the bedtime dose on the day of admission, both doses the following day, and the next morning dose were not administered. Nursing documentation showed the resident had severe cognitive impairment and was rarely or never understood, and there was no documentation that the primary care physician (PCP) was notified of the missed doses. Interviews and record review revealed that staff were aware the fidaxomicin had not been started because the medication was not covered by insurance and would have cost over two thousand dollars for ten tablets. The Infection Control/Assistant Director of Nursing (ADON) reported that pharmacy had indicated the cost issue, and she contacted the PCP to discuss changing the medication, but this occurred after the resident’s daughter discovered the ATB had not been started and requested transfer to the emergency room (ER). The ER physician documented that the resident had not received his ATB for C-diff for two days because the nursing home stated it was too expensive to be given, and the ER administered a dose of fidaxomicin and discharged the resident with a prescription for the remaining doses. A second resident with chronic obstructive pulmonary disease with acute exacerbation, schizoaffective disorder, bipolar disorder, intact cognition, and delusions was evaluated by a nurse practitioner (NP) for sinus symptoms and acute cough. The NP documented an order for Augmentin 500-125 mg by mouth twice daily for seven days for acute frontal sinusitis. The physician orders reflected this ATB order the next day, but the MAR showed no doses were given for the first two days after the order, with the first documented dose administered on the third day. The DON and Infection Control/ADON confirmed the delay, explaining that the NP’s order was in the progress note and not recognized by staff initially, and that weekend staffing with agency nurses, who did not have access to the emergency medication box and did not contact pharmacy, contributed to the failure to start the ATB on time, despite the medication being available in the emergency box. The facility’s medication administration policy required medications to be administered in a safe and timely manner as prescribed but did not address physician notification for withheld doses.
Failure to Administer Insulin per Order and Insulin Pen Instructions
Penalty
Summary
The deficiency involves the failure to administer insulin according to the physician’s order and manufacturer instructions for an insulin pen. A resident with type 2 diabetes mellitus, diabetic chronic kidney disease, and muscle weakness was care planned as being at risk for hyper/hypoglycemia, with an intervention to administer medications per physician orders. The physician’s order directed that NovoLog FlexPen insulin be given subcutaneously at 2 units before meals, with the dose held for blood sugar below 70. During a medication pass, an LPN removed the resident’s NovoLog FlexPen from the medication cart, attached a needle, dialed the pen to 2 units, and administered the insulin subcutaneously after the resident had finished breakfast, rather than before the meal as ordered. The LPN did not prime the insulin pen before administration. She confirmed that she only primes insulin pens when they are new and reported that she had previously broken pens when attempting to prime them, so she stopped priming altogether. The DON stated that insulin pens were to be primed before each use. Review of the insulin pen instruction manual showed that a safety test (priming) of 2 units must be performed before each injection to ensure the pen and needle are working properly and to ensure the correct dose is delivered. Additionally, review of the MAR showed that routine blood sugar results were not documented, despite the resident receiving daily hypoglycemic medication and insulin injections.
Failure to Administer Ordered Controlled Medications Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and that medications were administered as ordered. One resident with COPD, anxiety disorder, major depressive disorder, asthma, suicidal ideations, and unspecified convulsions had an active care plan for anxiety that required medications to be administered as ordered and monitored for effectiveness. This resident had a physician’s order for Ativan 0.5 mg by mouth twice daily for anxiety and agitation. Review of the MAR showed that the evening dose on one day and the early dose the following day were not administered, with progress notes documenting that the Ativan was unavailable and on order, and that the facility was waiting on pharmacy delivery. During an interview and observation period, this resident reported that the facility had run out of her Ativan and she had not received her doses. She was observed shaking, tearful, visibly upset, and in emotional distress, and required staff intervention. An LPN confirmed the missed doses and the resident’s distressed condition. The DON later verified that nine tablets of Ativan were actually available in the facility’s backup medication dispensing machine and explained that staff only needed a physician order and a pharmacy code to obtain the medication. A nurse practitioner stated that missing two doses of Ativan can cause disruption in treatment and increase the resident’s anxiety. A second resident with diagnoses including convulsions, stage four chronic kidney disease, major depressive disorder, cerebral infarction, and seizures had an active care plan related to sedative/hypnotic therapy, with interventions to administer medications as ordered and monitor side effects and effectiveness every shift. This resident had physician orders for Phenobarbital 32.4 mg every morning and 129.6 mg every evening for seizures and convulsions. MAR review showed that one evening dose was only partially available and not fully administered, and subsequent evening and morning doses were not given because the medication was unavailable and on order. The resident reported not receiving Phenobarbital since a prior morning dose, and an LPN confirmed the missed doses. The DON verified that four tablets of Phenobarbital were available in the facility’s override medication dispensing cabinet. Facility policies required that medications be administered as prescribed, that controlled medications be requested when a minimum five-day supply remained, and that medications be administered safely, timely, and in accordance with prescriber orders.
Failure to Administer Ordered Anti-Cancer Medication and Report Medication Error
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when a prescribed anti-cancer medication was not administered as ordered. The resident, admitted with diagnoses including secondary malignant neoplasm of bone, aplastic anemia, multiple myeloma not in remission, need for assistance with personal care, and adult failure to thrive, required staff assistance with multiple activities of daily living. A physician’s order directed that the resident receive Pomalyst 2 mg by mouth in the morning through a specified date. Review of the April Medication Administration Record showed that the resident did not receive the scheduled Pomalyst doses on two consecutive mornings. Nursing documentation indicated that on one of those mornings the nurse was unable to administer Pomalyst because it was not available in the medication cart. However, an RN later stated in interview that on the day of admission the family had brought in the medication, it was placed in the top drawer of the medication cart, and the order in the MAR reflected that location. The RN confirmed that the resident did not receive the ordered medication despite it being available in the cart. Additionally, there was no medication error report completed for the missed doses, contrary to the facility’s medication administration policy, which requires safe and accurate preparation and administration of medications according to physician orders and professional standards of practice.
Failure to Provide Ordered Vancomycin for C. diff Treatment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors and that medications were administered in accordance with physician orders. A resident with a recent hospital diagnosis of Clostridioides difficile (C. diff) had been started on oral Vancomycin 125 mg every six hours in the hospital, with treatment intended to continue through a specified end date. Upon admission to the facility, the physician ordered Vancomycin 125 mg every six hours for 37 doses. The resident’s record showed bowel incontinence on multiple occasions shortly after admission. The facility’s medication administration record listed scheduled Vancomycin doses at four specific times each day. Review of the medication administration record revealed that four scheduled Vancomycin doses were not given, with nursing staff documenting that the medication was not available. The missed doses occurred during the first two days after admission, and the first dose administered by the facility was not given until the evening of the second day. The times for administration were changed on the second day, but there was no evidence that the physician was notified that the ordered Vancomycin was unavailable. The Regional Nurse Consultant confirmed that Vancomycin was not in the facility’s starter kit, that the pharmacy was not contacted to supply the medication until the second day after admission, and that the resident missed four doses of the antibiotic with no documented physician notification.
Failure to Administer Insulin and Other Medications Timely and Obtain Ordered Blood Glucose Checks
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to untimely administration of ordered medications and failure to obtain ordered blood glucose checks. The resident, admitted with diagnoses including muscle weakness, need for assistance with personal care, chronic kidney disease stage 4, and intact cognition, had multiple physician orders including Buspirone three times daily, Ferrous Sulfate twice daily with meals, Humalog insulin 12 units subcutaneously with breakfast, Lactulose twice daily, Metoprolol Succinate twice daily with hold parameters, Xifaxan twice daily, and dialysis three times weekly. Physician orders also required blood sugars to be obtained for breakfast and dinner meals, and an NP progress note directed that blood sugars be sent to endocrinology. Review of the MARs and TARs for a specific date showed no evidence that blood sugars were obtained for either the breakfast or dinner meals. On the date of observation, the resident returned from dialysis around mid-morning and was observed on a transportation cart in the room, waiting for staff to transfer her to bed with a Hoyer lift. An LPN later confirmed that the resident had returned around that time and had eaten breakfast but that the LPN had fallen behind and was unable to administer the resident’s scheduled medications when due. The resident reported that there were not enough staff, that her medications were consistently administered late, and confirmed she had not received her morning medications or her ordered insulin with breakfast that day. A regional RN confirmed that the LPN had not administered the resident’s scheduled medications, including insulin, in a timely manner and also confirmed that the resident’s blood sugars, which were ordered to be obtained prior to breakfast and dinner, were not obtained as required on that date. The facility’s Medication Administration Policy stated that medications were to be administered as prescribed in accordance with good nursing principles and practices.
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