Medication Given to Wrong Resident: A resident with multiple chronic conditions, including Parkinson's disease, DM, epilepsy, dementia, and AFib, received another resident's scheduled morning meds in error. The nurse prepared the wrong resident's meds, did not verify identity using a second identifier, and administered them after the resident incorrectly identified himself as the other resident. The error was later recognized when the other resident reported the mix-up to nursing staff.
A newly admitted resident with multiple chronic conditions received two medications in error after admission because the Unit Manager transcribed the EMAR during multiple simultaneous admissions and interruptions. The hospital discharge summary did not include Buspirone or Benzonatate, yet both were entered on the EMAR and administered multiple times without documentation that the discrepancy was clarified with the provider. The facility's review identified the Buspirone error but missed the additional Benzonatate error.
Medication Reconciliation Errors Led to Missed Keppra and Eliquis Doses A resident with epilepsy, CVA, and a new DVT returned from the hospital with orders for Keppra via G-tube and Eliquis. The admitting nurse had difficulty entering the meds into PCC and forgot to complete the Keppra transcription, and only part of the Eliquis order was entered. As a result, Keppra was never transcribed or administered for 10 days, and the Eliquis 5 mg BID order was not transcribed or given for 5 days.
A resident with orthostatic hypotension had an order for Midodrine 10 mg BID with instructions to hold if SBP was greater than 120. Nursing administered the medication twice despite documented SBP readings of 128/72 and 129/69, and the nurse, NP, and DON all confirmed the doses should have been held based on the order.
A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
Medication administration errors occurred for two residents. One resident with dementia, Parkinson’s disease, and mood/behavior concerns had a Seroquel order that was not transcribed to the MAR for days, resulting in missed doses until the error was discovered after worsening behaviors. Another resident with ESRD and HTN received Metoprolol Tartrate and Midodrine outside the physician-ordered SBP parameters, and the DON and UM confirmed the meds were given or held contrary to the orders.
Medication Given Without Physician Order: An RN attempted to administer furosemide to a resident who had an order for torsemide 40 mg daily for edema. The RN stated she thought the two meds were the same and did not have a physician order to substitute them; another nurse retrieved the furosemide from the pyxis, and the surveyor stopped the administration before the incorrect med was given.
Incorrect Scheduling of IV Cefazolin: A resident with a hip prosthesis infection and moderate cognitive impairment was ordered IV cefazolin q8h by the hospital, NP, and ID consultant, but nursing transcribed it as TID at 10:00 A.M., 2:00 P.M., and 8:00 P.M. Interviews showed staff knew the medication should have been spaced evenly, and the MAR showed repeated administration at 10:00 A.M. and 2:00 P.M. instead of q8h.
A resident with bacteremia did not receive an ordered daily IV daptomycin dose when the medication was unavailable, and nursing documentation was inconsistent between the EHR MAR and paper infusion records. Interviews showed one nurse expected another nurse to administer the dose when it arrived, while another nurse could not confirm giving it and later said she did not administer it. The physician stated the antibiotic was important to receive daily and should have been given once available.
Medication Administered Outside BP Parameters: A resident with A-fib, HTN, and a hx of sudden cardiac arrest had orders for Amlodipine and Enalapril to be held if SBP was less than 110 mmHg. Review of the MAR showed both meds were given multiple times when SBP was below the ordered threshold, and the UM and DON confirmed the meds should have been held per the physician orders.
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