Significant morphine dose error: An RN administered 0.25 mL (5 mg) of morphine sulfate buccally instead of the ordered 0.1 mL (2 mg) dose to a resident with severe cognitive impairment, Alzheimer’s disease, CAD, and dementia. The RN said she followed the medication box label, while the unit manager confirmed the correct dose was on the EMAR. The resident was assessed afterward and remained unchanged.
A resident with chronic steroid use and multiple comorbidities returned from the hospital on a prednisone taper, but the order was not correctly transcribed into the EMR and the MAR showed no evidence the medication was given. The resident later developed hypotension and lethargy and was hospitalized with adrenal crisis; hospital notes stated the resident had been off steroids for 2 days and that the missed prednisone likely contributed to the adrenal insufficiency.
A facility failed to keep residents free from significant medication errors when nursing staff omitted or delayed many scheduled meds, treatments, and assessments for multiple residents. Errors included missed insulin, anticoagulants, narcotics, diuretics, blood pressure meds, blood glucose checks, wound care, and daily weights, with progress notes often lacking nurse assessments or provider notifications. Interviews showed staff were aware of the widespread omissions, some doses were not given because of time, and the DON and NP were not notified in a timely manner.
A facility failed to ensure medications were administered without significant errors for multiple residents. Errors included missed or delayed anticonvulsant doses, a missed propranolol dose with no BP/HR check for hold parameters, and a Klonopin dose never removed from the med drawer. Staff and the pharmacy consultant described the errors as related to distraction, rushing, fatigue, and poor medication documentation, and several of the affected residents had seizure disorders or other serious neurologic conditions.
A resident with chronic hyponatremia and SIADH had a clinically significant [NAME]-Na order transcribed incorrectly and then repeatedly omitted because the medication was not available or in short supply. The MAR showed multiple missed doses, and staff did not document notifying the provider or pharmacy about the omissions or the dosage discrepancy. The resident’s condition declined with worsening weakness, edema, SOB, and hospital transfers, while the DON acknowledged the missed doses were a significant medication error.
A resident with CHF, CKD, and diabetes had a Bumex dose increased for fluid overload, but an RN discontinued the new order without a matching physician order and the resident missed doses for two days. The resident then developed SOB, had low O2 saturation, was sent to the ED, received IV Bumex, and was hospitalized after imaging showed pulmonary edema and bilateral pleural effusions.
A resident with epilepsy, hallucinations, and parkinsonism received Haloperidol nightly for months even though no valid physician order was found in the chart. The med was entered into the electronic system as if it were ordered for the resident, transmitted to the pharmacy, and administered by staff despite the lack of a corresponding provider order. Records and interviews showed the order may have been intended for another resident, hospice records did not match the facility MAR, and the drug was later discontinued after seizure activity.
Significant Lactulose Medication Error: A resident with hepatic encephalopathy, cirrhosis, and convulsions received an incorrectly transcribed lactulose order in the MAR that listed 10 g/15 mL instead of the ordered 30 g/45 mL. The resident also missed initial doses because lactulose was unavailable, then received multiple doses at the lower amount after an LPN relied on the MAR despite the bottle label mismatch. The resident later developed seizure-like activity and was hospitalized with severe hyperammonemia and new onset seizures.
A resident with dementia and Alzheimer's disease ingested another resident's crushed medications after an RN prepared the medications in a glass, placed it in front of the intended resident, and walked away, leaving it unattended. The cognitively impaired resident took the glass, drank the contents, and became lethargic, with her pulse dropping from her usual rate to the 30s–40s bpm. She was sent to the ED, where it was determined she had ingested multiple medications, including metoprolol, and was diagnosed with a medication overdose and bradycardia requiring IV fluids and glucagon.
A resident with diabetes and multiple comorbidities experienced significant medication errors when rapid-acting insulin aspart, ordered as a sliding scale to be given with meals, was administered mid-afternoon without a meal and then inaccurately documented on the eMAR as noon and evening doses. Later that day, the resident was found incoherent, cold, and clammy with critically low blood glucose and required transfer to the hospital. Surveyors also observed that the same resident’s scheduled morning medications, including insulin glargine, cardiac, anticoagulant, pain, and respiratory drugs, were administered nearly three hours late, and the resident reported that medications were often more than an hour late, affecting pain control and breathing. The NP and pharmacist confirmed that rapid-acting insulin should not be given between meals and that key medications should be administered on a consistent schedule, while the DON and Administrator acknowledged these were medication errors.
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