Medication orders were not transcribed correctly for two residents. One resident with CHF and chronic pulmonary edema had a temporary Lasix increase ordered by an outside provider, but the EMR did not reflect the return to the ongoing dose, and staff confirmed the resident missed Lasix because of the transcription error. Another resident with type 1 DM returned from the hospital and the long-acting insulin order was not entered correctly, leaving the resident without scheduled glargine doses while staff were unsure who completed the order entry.
A resident with sepsis and severe cognitive impairment did not receive prescribed amoxicillin-clavulanate for a UTI as ordered. The MAR showed all doses were missed, yet nursing, NP, and IP documentation incorrectly stated the antibiotic was being given with no adverse reactions. Interviews confirmed the medication was unavailable, the provider was not kept informed after the initial call, and the resident’s record lacked documentation explaining why the antibiotic was not administered.
Missed anticonvulsant dose after admission: A resident with a seizure disorder did not receive the ordered evening dose of levetiracetam because the EMR entry defaulted the first dose to the next day. The MAR showed no dose during the ordered evening window, and the resident had two seizures the next morning before the medication was given. Nursing notes and provider interviews linked the missed dose to the seizure event.
The facility failed to follow medication orders for multiple residents. An LPN/RN administered an antihypertensive despite low BP parameters, gave Senna to residents with loose stools even though the orders said to hold it, and could not provide Eliquis and duloxetine during a med pass because the medications were not available. The DON and other staff acknowledged the orders and the missed or inappropriate administrations.
A resident received his ordered meds plus six meds belonging to another resident after an NP relied on an incorrectly uploaded chart and failed to verify the resident’s name and DOB before updating CPOs. The error was discovered during hospital med rec when the resident was sent out for a PICC line concern, and the resident had received one dose of each incorrect medication.
Two residents experienced significant insulin medication errors. One resident missed a scheduled rapid-acting insulin dose and blood glucose monitoring when an RN got behind on morning medication administration, and later had a blood glucose of 600 mg/dl. Another resident received 30 units of insulin glargine instead of 3 units after an RN dialed the wrong dose on the insulin pen; the resident’s blood glucose fell to 60 mg/dl and the resident became lethargic and had difficulty staying awake.
A resident with severe cognitive impairment and multiple neurologic diagnoses was prescribed cephalexin for a UTI, but the MAR and dispensing records showed multiple missed and inconsistently documented doses. The resident received some doses, but several were omitted, one dose was only half the ordered amount, and the physician was not documented as being notified about the missed antibiotic doses.
Medication Errors: BP Meds Given Outside Parameters Two cognitively intact residents with HTN had ordered hold parameters for antihypertensive meds, but the meds were still administered when SBP and, in one case, HR were below the physician’s limits. The EMR did not include progress notes explaining why the meds were given despite the ordered parameters.
A resident with type 1 DM, who was cognitively intact and ordered insulin lispro 20 units SQ before meals with pre-administration blood glucose checks, did not receive the ordered morning insulin dose. After the resident reported having eaten breakfast, an LPN obtained a blood glucose of 205 mg/dl, discovered the insulin vial was empty, and then administered the resident’s other medications but did not obtain insulin from other facility sources, notify a supervisor, or call the pharmacy at that time. The LPN later documented on the MAR that the blood sugar was 125 mg/dl and that the insulin was given, despite it not being administered. A subsequent lunchtime blood glucose by an RN was 191 mg/dl, and documentation that the morning insulin dose was missed was entered only after the issue was raised to facility leadership.
Medication administration errors involved one resident who did not receive scheduled IV antibiotics on time after transfer, with missed and delayed doses of vancomycin and piperacillin-tazobactam and no documentation that the pharmacy or ID team was notified. Two other residents had BP meds given or held outside ordered parameters, including metoprolol, lisinopril, amlodipine, isosorbide dinitrate, and sotalol, with inconsistent CPOs/MAR documentation and no documented provider contact for low BP or a missing dose.
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