A resident with anxiety disorder and intact cognition missed multiple doses of alprazolam when the medication ran out and was not reordered in time. MAR entries and nursing notes showed the doses were marked as on order or out of medication, and staff interviews confirmed the pharmacy had not received a refill request and emergency stock was not used to bridge the gap.
A resident with Huntington’s disease and methadone therapy experienced a medication-related emergency after the facility did not clarify the Narcan order on admission, did not have Narcan immediately available, and had staff who lacked access and training for the Medbank. The resident later became cyanotic and unresponsive, was transferred to the ER, and the hospital documented acute respiratory failure and opioid intoxication. The record also showed inaccurate measurement of titrated liquid methadone doses, with staff using a syringe that could not accurately measure odd mL doses.
Medication Error Caused Resident Sedation and Hospitalization: A resident with HF, DM, and dementia became unresponsive after receiving another resident's meds, including amoxicillin, quetiapine, and levetiracetam. Staff reported the CMA prepared meds from memory without using the MAR, and the resident was later hospitalized with significant sedation, low BP, and low HR. The resident said she remained groggy and not back to baseline after the event.
Significant insulin administration errors occurred when ordered insulin was not given or not documented as given for multiple residents with diabetes and other serious conditions. A nurse working an unfamiliar hall acknowledged forgetting insulin doses while residents had elevated blood sugars, including repeated HI readings for one resident, and the MARs showed several scheduled basal and sliding-scale insulin orders were left incomplete without progress notes explaining why.
Two residents missed their scheduled evening medication pass when meds were found in envelopes stapled or taped to their bubble packs, yet the MARs showed the doses as administered. One resident had no cognitive impairment and diagnoses including renal insufficiency and malnutrition; the other had severe cognitive impairment with diagnoses including dementia and a blood clot history. Staff and the DON confirmed the missed doses, and one resident’s regimen included Eliquis, a high-risk medication.
A resident with chronic pain received an extra opioid dose instead of the ordered PRN analgesic, and the MAR did not reflect the second administration or required monitoring. The resident later required ER evaluation after the opioid error was discovered. Another resident reported missed midday and afternoon meds, but the MAR showed them as given even though staff later said the resident was unavailable and the documentation was inaccurate.
A facility failed to prevent wrong-resident medication administration for three residents. One resident with intact cognition, one resident with moderate cognitive impairment, and one resident with severe cognitive impairment each received another resident’s meds during morning pass, including multiple cardiac, diabetic, anticonvulsant, antibiotic, and diuretic agents. Staff reported being distracted or sidetracked while preparing meds and then giving a med cup from the cart without properly identifying the resident, despite the facility’s policy on wrong-person errors and the 6 rights of med administration.
Medication Orders Not Available or Administered as Prescribed: Two residents did not receive ordered meds as prescribed. One resident with pain, cancer, and constipation had a buprenorphine patch order entered incorrectly after hospitalization, and the MARs lacked documentation that the patch was given. Another resident with COPD had a Trelegy Ellipta inhaler unavailable for several days, with pharmacy and staff interviews showing delays in reordering and receipt. Facility policy required timely pharmacy contact, documentation, and order updates after hospitalization.
Missed and delayed medication administration: A resident with intact cognition did not receive Levothyroxine and Acyclovir as ordered. The MAR showed missed documentation for Levothyroxine and multiple missed Acyclovir doses, while staff reported the antiviral was not given because the supply had not been located in the cart and the order was later revised after the pharmacy said the medication had been delivered.
Two medication management failures were identified. One resident with diabetes and intact cognition did not receive ordered mealtime insulin on two occasions because staff misread the order as a duplicate, and the DON confirmed the nurse should have verified and administered it as ordered. Another resident with a history of DVT and PE continued to have Xarelto listed on the MAR after a hospital stay for vaginal bleeding in which the anticoagulant had been discontinued; the resident repeatedly refused it, and the order remained active until later review by the physician and NP.
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