A resident received a double dose of Retacrit after an order was transcribed incorrectly from weekly to every shift. The resident’s cardiology note had recommended increasing Retacrit from 20K units weekly to 40K units weekly, but the order was entered incorrectly and the medication was administered twice in one day by nursing staff. The DON verified the findings.
A resident was ordered Zinc 220 mg, but the facility only had Zinc 50 mg tablets in stock and staff had been administering 4 1/2 tablets to equal 225 mg. The UM stated she was unaware of the dosage discrepancy and that the resident was receiving a different pill count to approximate the ordered dose.
An LPN administered 21 units of insulin to a resident with DM even though the active MAR order directed 18 units daily. The LPN said the MD had verbally increased the dose, but the MAR had not been updated. Policy review showed staff are to verify the MAR against the medication source and properly document verbal orders, and the DON and ADON acknowledged the dose mismatch was a significant med error.
A resident was readmitted from the hospital, but the receiving RN did not enter the new med orders into the EHR. Only acetaminophen was on the MAR, while Eliquis and other ordered meds were missing. The resident later had leg pain, the missing anticoagulant doses were discovered, and the resident developed a clot requiring a thrombectomy.
A resident’s MAR and physician orders showed that acetaminophen was administered in amounts exceeding the ordered 3 g/24 hr maximum when both scheduled and PRN doses were given on the same days. The same resident had PRN orders for oxycodone 5 mg q6h for mild to moderate pain and oxycodone 7.5 mg q6h for severe pain rated 7–10, yet received oxycodone 7.5 mg doses before the 6‑hour interval elapsed and for pain scores below the ordered severity range. Facility staff, upon review with surveyors, acknowledged these administrations as medication errors.
A resident with a history of STEMI, CHF, A-fib, chronic embolism/DVT, and hypertensive heart disease was discharged from the hospital with instructions to switch from Eliquis to Xarelto, including a loading dose followed by a maintenance dose. Although Xarelto was ordered on admission, multiple erroneous Eliquis orders were entered by the pharmacy and verified by an LPN supervisor, then repeatedly discontinued by an RN Unit Manager who recognized that only Xarelto was intended. Despite these actions, Eliquis continued to appear on the MAR, and an LPN ultimately administered Eliquis 5 mg together with Xarelto 15 mg during a morning med pass, resulting in both anticoagulants being given concurrently and increasing the resident’s risk for bleeding.
A resident with severe cognitive impairment and multiple neurologic and psychiatric diagnoses had a documented allergy to acetaminophen in the clinical record. Despite this, a physician later ordered scheduled Tylenol for pain in the same note that listed acetaminophen as an allergy, and the medication was administered. The resident’s MPOA reported that the MD prescribed a drug to which the resident was allergic, and in interviews the MD acknowledged missing the allergy, noting that nursing staff and the pharmacy also did not detect the error. Facility leadership stated that the medication error was not identified or documented at the time and was only recognized after the resident’s daughter reported it months later.
A resident was admitted from a hospital with discharge instructions for Eliquis BID, amiodarone QD, and Buspirone BID, but nursing staff used an outdated hospital discharge summary from a prior hospitalization when entering admission orders. As a result, the facility ordered and administered Eliquis QD instead of BID, amiodarone BID instead of QD, initiated Losartan that was not on the current discharge list, and delayed starting Buspirone. The DON later acknowledged that staff misread the date on the discharge summary, and the errors continued for several days until identified by the family.
Late Administration of Time-Sensitive Seizure Medications: A resident reported that seizure medications were being given late, and audit findings confirmed multiple late administrations of Levetiracetam and Lamotrigine by nursing staff. The DON reviewed the findings and confirmed that staff are expected to administer medications within a 1-hour window before to 1-hour after the due time.
A resident with a seizure history and intact cognition had an active order for Dilantin, with care plan instructions for staff to administer medications as ordered. After lab results showed an elevated Dilantin level, an LPN documented that the physician ordered the Dilantin to be held and the level rechecked. Despite this, the medication administration record showed the LPN administered another dose of Dilantin later that same day. The physician, ADON, DON, and Administrator all confirmed that the dose was given after the hold order, constituting a significant medication error.
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