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.
A resident with a history of stroke and seizure disorder was ordered Vimpat 50 mg PO BID, but an incorrect 200 mg BID dose was entered into a separate e-script system and filled by the pharmacy. The eMAR continued to show a 50 mg dose, yet four LPNs administered 200 mg tablets for four doses, as evidenced by missing tablets and narcotic count signatures, while documenting 50 mg on the MAR. The DON later explained that the EMR used for orders was not linked to the narcotic e-script system and there was no reconciliation process between the e-scripted narcotic order and the physician order in the chart, leading to the resident receiving a higher-than-ordered dose.
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.
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.
The facility failed to ensure methadone was administered according to physician orders, resulting in significant medication errors for multiple residents on methadone maintenance therapy. Policy required nurses to use the eMAR as the source for medication administration and to verify the five rights, but methadone bottles for several residents carried doses that did not match the physician orders entered in the electronic record, despite daily administration being documented. Nursing staff reported either not cross-checking bottle dosages against orders or relying solely on the bottle label or resident familiarity, and they often did not notice discrepancies. The attending physician, DON, and medical director described a process in which the methadone clinic determined doses, nurses transcribed bottle labels or clinic information into the electronic record, and physicians signed orders without independent verification or direct clinic documentation, contributing to inconsistent and inaccurate methadone dosing information.
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.
A resident with Parkinson’s disease, dementia, and anxiety received another resident’s potent medications, including opioids and other CNS-acting drugs, after an LPN pre-poured medications for about 20 residents and misidentified a pill, administering the wrong medication cup. Facility policy required correct resident identification and adherence to the six rights of medication administration, but the LPN’s pre-pouring and misadministration led to the resident receiving an incorrect regimen. Subsequent documentation showed hypotension, bradycardia, lethargy, and decreased respirations, with limited and delayed physician notification and incomplete nursing documentation of the resident’s changing condition, culminating in the need for Narcan as ordered by the physician.
Medication Pass Error Rate Exceeded Allowed Threshold: Surveyors found an 11% medication error rate during a med pass observation. An LPN selected the wrong eye drop for one resident, another LPN recognized that metoprolol should be held because the resident’s BP was below the ordered parameter, and a third LPN administered a late dose of midodrine and began changing the MAR time to match the scheduled time instead of the actual administration time.
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.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
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