Glaucoma Eye Drops Inappropriately Held Without Orders, Leading to Prolonged Missed Doses
Summary
The deficiency involves a resident with bilateral primary open-angle glaucoma whose prescribed glaucoma eye drops were placed on hold without a physician’s order, resulting in numerous missed doses over an extended period. The resident, an older female with severe stage bilateral glaucoma and moderately impaired vision, had active diagnoses of unspecified open-angle glaucoma and used corrective lenses. Her care plan included administration of glaucoma medications (Latanoprost 0.005% once daily and Dorzolamide 2% twice daily) as ordered to relieve or minimize ocular pressure. During a night-shift medication cart audit, an ADON identified that the resident’s glaucoma eye drops were expired, removed them from the cart, and unilaterally placed both medications on hold in the electronic MAR without obtaining a physician’s order, documenting that the medications were on hold pending refill from hospice pharmacy. Following this action, the resident’s Latanoprost was on hold for a period during which 25 doses were missed, and Dorzolamide was on hold for a longer period during which 47 doses were missed. Multiple nurses, including LVNs and the weekend RN supervisor, reported that they were told by the ADON that the medications were on hold due to expiration and pending delivery, and they assumed that appropriate physician orders and notifications had been obtained because the ADON had executed the hold. The hold orders were entered without a stop date, and there was no documentation that the physician, NP, hospice, pharmacy, or the resident’s family had been notified at the time the medications were placed on hold. Staff interviews indicated that the eye drops’ unavailability and hold status were mentioned intermittently in morning clinical meetings and 24-hour reports, but there was no effective follow-through to secure replacement medications or clarify orders, and the medications remained on hold for nearly a month. The resident herself noticed that she was not receiving her usual glaucoma eye drops and reported this to her family member. The family member later contacted facility staff and hospice, expressing concern about the interruption in therapy and lack of communication. Subsequent review of records and interviews confirmed that hospice did not cover the glaucoma medications and had not been previously notified of any change, that the facility pharmacy had delivered Dorzolamide earlier than staff realized, and that Latanoprost had not been requested for refill for an extended period. The physician and MD later reported they had not been notified when the medications were placed on hold, and the ophthalmology office confirmed the resident’s glaucoma was severe and that the prescribed drops were intended to keep intraocular pressure down and prevent further optic nerve damage. The facility’s internal investigation and staff statements consistently showed that the ADON placed the medications on hold without a physician’s order, failed to follow up to ensure timely reordering and delivery, and that floor nurses relied on the ADON’s actions and did not independently obtain orders or restart the medications, resulting in the resident missing a significant number of prescribed glaucoma medication doses. Additional interviews with the Interim DON, Clinical Services Director, pharmacy consultant, hospice nurse, and other staff further detailed the sequence of inactions that led to the prolonged interruption of therapy. The Interim DON and CSD stated that any medication placed on hold should have an associated physician order, with clear start/stop parameters, and should be tracked via reports and discussed in clinical meetings until resolved. They reported that in this case, the hold orders for the glaucoma drops lacked a physician order and stop date, and the issue was not consistently or effectively addressed in daily clinical oversight. The hospice nurse reported learning of the discontinuation only after a family call and stated that the ADON acknowledged placing the drops on hold and forgetting to follow up. The MD and pharmacy consultant explained that failure to receive glaucoma medications could allow intraocular pressure to increase and glaucoma to progress, and the ophthalmology assistant emphasized that once vision loss occurs from glaucoma, it is permanent. Collectively, the documentation and interviews show that the resident was not kept free from significant medication errors because her essential glaucoma medications were inappropriately held without medical authorization and without timely follow-up, leading to a prolonged period in which she did not receive the prescribed therapy. Throughout this period, multiple staff members, including LVNs, the weekend RN supervisor, and a medication aide, were aware that the eye drops were on hold and unavailable, but they either believed the ADON had already obtained necessary orders or lacked authority to change the hold status. The resident’s family member and hospice nurse ultimately brought the issue to higher-level attention after discovering that the resident had gone without her glaucoma medications for nearly a month. Interviews with the Administrator and Interim DON confirmed that they were not promptly informed when the family first raised concerns over a weekend, and that the ADON, who was responsible for pharmacy systems and medication availability, did not ensure that the medications were reordered, delivered, and restarted. As a result, the resident missed dozens of doses of both Latanoprost and Dorzolamide, contrary to her care plan and physician’s original orders, constituting a significant medication error. The report also documents that the resident did not report pain, blurry vision, or noticeable vision loss during the period without eye drops, and that she continued to use glasses for near and far vision. However, clinical experts interviewed in the report noted that glaucoma is often asymptomatic, that increased intraocular pressure is not felt by the patient, and that progression of glaucoma and associated vision loss can occur over time without obvious symptoms. The facility’s own clinical leadership and external consultants characterized the interruption of glaucoma therapy as a serious concern, and the Clinical Services Director stated she would consider the situation a form of neglect. The deficiency is therefore based on the facility’s failure to ensure that the resident was free from significant medication errors by allowing her prescribed glaucoma medications to be held without proper authorization or follow-up, resulting in a prolonged lapse in treatment.
Penalty
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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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