A resident with diabetes and sleep apnea did not receive ordered tirzepatide on multiple scheduled doses over several months. MAR review and staff interviews showed the medication was repeatedly unavailable, with notes such as waiting on pharmacy or not in stock, and some missed doses had no explanation documented. The resident reported missing doses about once per month and experiencing nausea and fatigue when doses were skipped, while the DON, MD, and NP were unaware the medication was not being given as ordered.
A nurse crushed and administered two ER medications to a resident with heart failure even though one order said not to crush and the other was an ER tablet that should not be crushed. The nurse said she was unaware of the instructions, while the pharmacist, DON, and MD confirmed that crushing ER meds alters their release characteristics and is not appropriate.
A nurse failed to follow a resident’s insulin order by checking the blood sugar after breakfast was finished and then giving scheduled and sliding-scale Novolog based on that post-meal result. The resident had diabetes and was ordered insulin before meals, but the nurse said she often could not complete blood sugars and insulin administration before breakfast because of time constraints. The PA and DON both stated the order should have been followed as written.
Medication Error Caused Severe Bradycardia and Hospital Transfer: A severely cognitively impaired resident with sinus bradycardia received his scheduled AM meds and then was mistakenly given another resident's meds, including metoprolol succinate ER, amlodipine, tamsulosin, and donepezil. He became lethargic with HR in the 30s to 40s and BP 90/60, was sent to the hospital, and was diagnosed with severe symptomatic bradycardia, hypotension, and progression to complete heart block requiring epinephrine, atropine, and a dual-chamber pacemaker.
Medication Administered in Incorrect Form: A resident with dementia and other chronic conditions received metoprolol succinate ER, carbidopa-levodopa ER, and duloxetine DR in the wrong form when an RN crushed two tablets and opened one capsule into applesauce. The RN relied on verbal report and a hall list instead of reading the resident’s orders, despite an order stating the resident takes medications whole and orally. The NP and DON both stated the medications should not have been given that way.
A resident with traumatic brain injury, post traumatic seizures, and severely impaired cognition had anticonvulsant orders transcribed and administered incorrectly after readmission. The ADON entered the correct zonisamide and lacosamide doses from the final verified hospital discharge summary, but the DON later changed the orders using a preliminary discharge summary and did not clarify the discrepancy with the hospital or the admitting nurse. The MAR showed repeated administration of lower-than-ordered doses before the orders were later corrected.
Failure to Transcribe and Administer Ordered Diuretic: A resident with CHF and other serious diagnoses returned from the hospital with orders for Furosemide 40 mg daily and PRN for weight gain, but the medication was not transcribed or given for five consecutive doses. The DON confirmed the discharge summary lacked the second verification checkmark, an LPN reported a verbal discontinuation by an NP that was not documented, and the MAR showed no Furosemide administration during the missed-dose period.
Failure to Stop Time-Limited Prednisone Order: A resident with multiple chronic conditions returned from the ED with a short-term prednisone order for COPD, but an LPN failed to enter a stop date in the EMR. As a result, the steroid remained active on the MAR and was administered daily far beyond the intended 5-day course. The resident later deteriorated with hypoxia, RSV, sepsis, and acute respiratory failure, and the physician stated prolonged steroid use could have reduced the resident’s ability to fight infection and may have contributed to the resident’s death.
Medication error: Lyrica given to resident with documented allergy. An MA administered another resident’s meds, including Lyrica, to a resident who had a documented Lyrica allergy after a temporary room change was not reflected on the door or in the computer system. The aide called out the wrong resident’s name, the resident responded, and the meds were given before the error was recognized. The resident had a prior reaction to Lyrica described as rash and swelling, and staff later identified the error as significant.
A resident with atrial fibrillation, recurrent falls, and severe cognitive impairment was readmitted after a hospital stay in which Eliquis was deemed unsafe and discontinued due to repeated falls and bleeding risk. Although the hospital orders showed Eliquis crossed out and initialed by the PA, an RN entered Eliquis 5 mg BID into the EHR, and the second verification step was not completed. The MAR showed 27 doses were given in error until the resident fell with a head strike, at which point the PA identified the medication error and the resident was sent for evaluation.
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