Medication administration observations found a 6.25% error rate, exceeding the allowed threshold. An LPN gave a resident with Alzheimer’s disease and HTN the wrong dose of amlodipine after a recent order change was not properly matched to the blister pack, and another LPN prepared magnesium using a substitute strength without an order for a resident with hypomagnesemia, dementia, and diabetes. The RN unit manager and DON stated orders should be followed as written and substitutions should not be made without an order.
Medication error rate exceeded the 5% threshold after surveyors found errors during 33 med observations. An LPN allowed a resident with schizophrenia, DM, and ESRD to self-administer fluticasone without a self-administration order or care plan, left hydrocortisone cream at bedside, and administered artificial tears from a bottle with conflicting open/expiration dates to another cognitively intact resident with COPD, HTN, and anxiety; the DON confirmed the resident was not approved for self-administration.
Medication error rate exceeded the 5% threshold after surveyors found errors during medication pass observations. For one resident, the MAR and blister pack conflicted on Depakote dosing, and the RN, LPN/unit manager, and DON could not determine the correct order. For another resident, medications were being crushed without a located provider order, and the DON could not find the order during the survey.
Medication Pass Error Rate Exceeded Allowed Threshold: An LPN administered several scheduled meds to a resident with dementia, anemia, HTN, and atrial fibrillation more than 2 hours late, resulting in an observed med error rate of 12.5% and exceeding the required threshold. Staff interviews showed inconsistent expectations and communication about notifying the nurse manager, NP, MD, and DON when meds were late or missed.
A resident with hemiplegia, hemiparesis, stroke history, and major depressive disorder had a Depakote dose mismatch between the physician order and the blister pack/MAR. An RN and LPN/unit manager both said to follow the computerized MAR, while the DON could not determine the correct order and stated the facility kept using the old blister pack after order changes until it was finished.
A resident with severe cognitive impairment and chronic pain syndrome received repeated oxycodone HCl 10 mg doses despite an order that was entered without required details and was verbally understood differently by staff. The DON identified the issue as a medication error, and an LPN stated they did not closely read the order and there was no system to verify new orders for accuracy.
Medication Administration Errors Exceeded Allowed Rate: An LPN failed to administer and document three scheduled 9:00 AM meds for a resident with Parkinson’s disease, OA, anxiety, and severely impaired cognition. The chlorhexidine oral rinse, fluoride paste, and zinc oxide-white petrolatum paste were not given during observation and were later charted hours after the scheduled time, contributing to a 9.375% med error rate; the RN manager, RN clinical leader, and DON stated meds were to be given and documented at the correct time and that supervisory staff and the MD should be notified if they could not be administered as ordered.
Medication Pass Failed to Include Expiration Date Checks: During a medication pass, an LPN administered medications to two cognitively intact residents without checking expiration/beyond use dates, despite facility policy requiring the dates be checked before administration. One resident received five medications and another received five medications, and the LPN stated they did not routinely check expiration dates prior to giving meds.
Multiple residents had significant medication errors, including missed or undocumented doses of insulin, transplant medications, antibiotics, anticoagulants, anticonvulsants, and cardiac medications, along with numerous doses given outside ordered timeframes. One resident with diabetes and transplant history was self-administering insulin without documented assessment or care plan support, while other residents had repeated late or omitted doses and staff reported medication availability and staffing problems, with no documented provider notification for the errors.
A resident with COPD, diabetes, heart failure, and depression had multiple scheduled medications and continuous O2 at 3 L/min ordered for the evening shift, but an RN did not administer the 4 PM, 8 PM, or 9 PM doses and did not ensure the resident received ordered oxygen, nor did the RN notify a supervisor or MD of the missed doses. The RN assumed the resident was with a visitor, did not verify the resident’s return, and only began looking for the resident later in the shift. The resident was ultimately found on the floor unresponsive without O2 in place, CPR was initiated, EMS assumed care, and the resident was pronounced deceased. Supervisory staff and the MD reported they were not informed during the shift that the resident was missing or that medications and oxygen had not been provided, and records showed no hourly safety checks or medication administration during the relevant period.
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