A resident with severe cognitive impairment and multiple diagnoses, including ESRD and dementia, was given doxycycline for URI even though tetracycline was listed as an allergy and the chart generated a drug-allergy alert. Staff later recognized the issue, and the NP changed the antibiotic, but the MAR showed the dose had already been administered by an MA.
Insulin pens were not primed for two residents receiving sliding-scale insulin. An LPN administered Novolog to one resident and Novolin R to another without performing the required safety test, despite both residents having diabetes and active insulin orders. The LPN stated she was unaware the pens had not been primed, and the DON, ADON, and Administrator stated insulin was expected to be given according to manufacturer instructions and physician orders.
Medication Held Outside Ordered Parameters: A resident with HTN and severe cognitive impairment had metoprolol tartrate held twice even though BP readings were within the prescriber’s hold parameters. The DON stated the medication should have been administered, while the RN said she used nursing judgment to hold it without contacting the MD, despite the order requiring administration unless SBP was below 100 or DBP was below 60.
Two residents received Potassium Chloride ER tablets crushed and mixed with yogurt even though the blister packs stated to swallow whole and not chew or crush. An MA crushed the potassium along with other meds and gave it by mouth to both residents, despite physician orders and MARs for daily ER potassium. One resident had severe cognitive impairment and diagnoses including low potassium, while the other also had severe cognitive impairment and diagnoses including low potassium, aphasia, and other serious conditions. The DON stated she was unaware of the issue.
A resident with HTN and atrial fibrillation had orders for amiodarone, metoprolol, and lisinopril to be held if HR/pulse was below 60, yet the MAR showed the meds were documented as given when the resident’s HR was 43 and 56. The MA stated she had held the meds because of the low HR but signed them off as administered, while the RN stated the MA should have held the meds and notified the nurse for reassessment.
Expired insulin was administered to a resident with diabetes when an LVN checked the resident’s blood sugar, prepared Novolog, and gave 2 units before noticing the vial appeared to be expired. The resident was cognitively intact and had orders for sliding scale insulin. The DON and Administrator stated nurses were expected not to give expired insulin, and facility policy required medication to be administered per order and opened vials to be dated and discarded within the required timeframe.
Failure to administer ordered potassium medication: an LVN dissolved Effer-K for a resident with hypokalemia, but the resident drank only part of the dose and the remainder was discarded. The LVN knew the resident would not finish it and did not notify the ADON, DON, or MD. The resident had severe cognitive impairment and a low K level was later found.
Missed Hydroxyurea Doses on Admission: A resident with thrombocytopenia, chronic myeloproliferative disease, and CML did not receive ordered Hydroxyurea on admission. The hospital discharge order called for Hydroxyurea 500 mg every other day, but the med was not entered promptly, pharmacy delivery was delayed, and the MAR showed the first documented dose was not given until several days later. The family member reported the resident missed his chemotherapy med for three days, and staff interviews showed uncertainty about who completed the admission med review and when the order was obtained.
A resident with Alzheimer’s disease, severe cognitive impairment, and a urea cycle metabolism disorder missed approximately 57 doses of lactulose after a temporary increased-dose order was entered and the routine order was discontinued in error. The MAR showed the medication was given as ordered until the temporary increase ended, then not administered for weeks despite the NP’s expectation that the resident would continue his regular lactulose regimen. The resident also had elevated ammonia and ongoing behavioral incidents, including an altercation that resulted in psych transfer.
A resident with a seizure disorder missed multiple scheduled doses of clonazepam and phenobarbital when the meds were not available, were awaiting pharmacy delivery, or could not be pulled from the automated med system. MAR entries and progress notes showed repeated gaps in administration, and staff documented jerking, vomiting, and use of home supply when the facility could not provide the ordered seizure meds.
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