A resident with multiple complex conditions and g-tube dependence experienced several medication administration errors by an LPN during a medication pass. The LPN gave aspirin with an unreadable expiration date, failed to administer ordered thiamine and lactulose due to unavailability in the cart, did not assess bowel status or give Miralax as intended, and administered a steroid nebulizer before a bronchodilator. The LPN also delivered only 330 ml instead of the ordered 360 ml of Glucerna 1.5 via g-tube and removed a scopolamine patch applied the previous day without verifying the order or replacing it, despite an active 72-hour order. These actions did not follow physician orders or facility medication and enteral feeding policies.
An orientee LPN, while paired with preceptors, twice failed to verify resident identity and administered medications prescribed for one resident to another. In one shared room, a cognitively intact resident stated the roommate’s name, and the LPN did not check the ID band, resulting in administration of diabetes, reflux, and mood-stabilizing meds intended for the roommate. On another occasion, the LPN was told to give meds to a specific roommate but instead gave a regimen including Jardiance, Metoprolol, Protonix, PreserVision, and Eliquis to the wrong roommate, who had different active orders and later developed hypotension and hypoxia requiring hospital admission. Facility policy required verification of the “five rights” and prohibited giving one resident’s meds to another, yet the orientee was allowed to pass meds independently, and the orientation checklist for the LPN was blank.
A resident with multiple medical conditions was admitted and had medications reconciled by an LPN/UM who failed to verify that all pages of a multi-page medication list belonged to the correct individual, resulting in transcription of another resident’s psychotropic and cardiac medications into the new admission’s EMR and MAR. These incorrect medications, including furosemide, lithium ER, trazodone, clonazepam, and risperidone, were then administered over several days until the resident’s representative questioned the accuracy of the list and reported that the resident was not completing sentences. Review of records and staff interviews confirmed that the medications actually belonged to another resident and that the provider had been given inaccurate information when admission orders were obtained.
An LPN administered IV antibiotics to two residents in error, giving each the other's prescribed medication due to failure to follow medication administration protocols, including the 5 Rights and required checks. One resident experienced an adverse drug reaction and required hospital admission, while the other was monitored without incident. The error was discovered after the infusions were completed, with staff noting that medication bags were clearly labeled but not properly verified before administration.
A nurse administered insulin intended for one resident to another, cognitively intact resident, after becoming distracted and failing to follow required identification and medication verification protocols. The nurse did not adhere to the facility's policy for verifying resident identity and medication details, resulting in a significant medication error.
A resident with severe cognitive impairment was mistakenly given another resident's medications by an agency LPN who failed to verify the resident's identity and did not report the error. The error was not documented, and the facility only learned of the incident after the resident was hospitalized for nausea, vomiting, and an upper GI bleed. The incident was not reported or documented by the nurse, and staff were unaware until notified by the hospital.
A resident with hypertension and heart failure did not receive 14 doses of a prescribed antihypertensive medication due to unavailability, with missed doses documented in the MAR and no evidence that the physician was notified. The resident was later transferred to the hospital for uncontrolled hypertension and diagnosed with a hypertensive emergency. Nursing staff confirmed the medication was not available, and facility leadership was unaware of the issue until the survey.
Two residents with pain management needs received their prescribed narcotic medications outside the required administration window on multiple occasions. Nursing staff confirmed that medications should be given within one hour of the scheduled time, but audit reports showed repeated late administrations, contrary to facility policy and prescriber's orders.
A nurse administered the wrong IV antibiotic to a resident with multiple infections, including MRSA bacteremia, by failing to verify the medication before administration. The nurse brought two IV medications into the room, intended for different patients, and gave Ceftin instead of the prescribed Daptomycin. The error was discovered within minutes, and staff interviews confirmed that facility policy and the five rights of medication administration were not followed.
A resident receiving IV antibiotics for bacteremia was given daptomycin and ceftaroline fosamil outside of the prescribed administration times on multiple occasions. Facility staff, including an LPN and the DON, acknowledged the expectation to administer medications within one hour of the scheduled time and to notify the provider if late, as outlined in facility policy. Despite this, the antibiotics were not administered as ordered.
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