A resident with mycobacterium avium complex and moderate cognitive impairment was prescribed Arikayce inhalation suspension for a pulmonary infection, but the MAR showed six missed doses. An LPN stated she was unfamiliar with the medication and its Lamira nebulizer setup, RT was to give it on weekdays and floor nurses on other days, and the resident had to show her how to set it up. The record also showed the physician was not notified when the medication was not administered.
A resident with Parkinson’s disease experienced repeated late administration of scheduled carbidopa-levodopa doses, and one dose was given so late that it resulted in a duplicate dose the next morning. The resident stated the Parkinson’s meds were not given on time, while an LPN and the DON were unsure whether the timing issues constituted a med error or what risks were associated with delayed or duplicated dosing.
A resident with Parkinson’s disease experienced 38 late administrations of Carbidopa-Levodopa, a time-sensitive medication ordered four times daily within specific windows. MAR review showed multiple doses given well outside the ordered times, including morning, noon, evening, and bedtime doses, and the resident reported medications were not always given when scheduled. An LPN confirmed the charted times reflected when the medication was actually administered, and the DON acknowledged the medication should have been prioritized within the scheduled window.
A resident with COPD, bipolar disorder, oxygen dependence, moderate cognitive impairment, and hospice status received multiple pain and anxiety meds in a short span, including oxycodone, morphine, methocarbamol, and two lorazepam doses that were given too close together and at double the ordered dose. The MAR and controlled substance record showed the lorazepam was not administered per the physician order, and the facility did not document a licensed assessment or physician consultation before giving meds outside the ordered timing.
Medication administration errors were identified for three residents. Two residents with orders for Apixaban missed scheduled doses, and one resident with a G-tube order for Truvada had multiple doses documented inconsistently or as unavailable while progress notes stated the medication was not available or the facility was waiting for pharmacy. The MAR also showed entries that conflicted with other nurses’ documentation that the medication was unavailable.
A review of MARs and TARs showed that 13 of 13 sampled residents on the Sparkle unit missed multiple ordered meds during the night shift, including antihypertensives, insulin, anticoagulants, anticonvulsants, psychotropics, and other routine medications. Staff interviews indicated there was no nurse covering the back part of the unit until late in the shift, the LPN found the meds already overdue, and the physician was not notified.
A resident admitted with atrial fibrillation and other conditions had physician orders for Xarelto and Amiodarone but missed multiple scheduled doses of both drugs because they were unavailable. Nursing documentation noted that one of the medications was held due to unavailability, yet there was no evidence that the provider was notified or that a medication error report was completed, despite facility policy defining unavailable medications as medication errors and requiring timely reporting to the DON or administrator. The NHA later stated they were unaware of the missed doses and that the expectation would have been to contact the physician for further orders.
The facility failed to ensure accurate and continuous administration of critical medications, including antirejection agents, an anticonvulsant, and warfarin. A resident with kidney and pancreatic transplants went without prescribed Mycophenolate Mofetil for over a month and Tacrolimus for several days due to breakdowns in communication and follow-through between facility staff and the pharmacy, leading to significant anxiety, fear, and depression for the resident. Another resident missed several days of ordered Lacosamide for seizure prophylaxis when the drug was repeatedly documented as not available or pending delivery. A third resident did not receive warfarin according to hospital discharge instructions, instead receiving a higher, variable dosing schedule, and a fourth resident received a double dose of warfarin when a previous order was not discontinued. These events were cited as significant medication errors, with one resident experiencing actual psychosocial harm and others placed at risk for more than minimal harm.
A resident with an infected prosthetic knee joint and intact cognition was ordered IV vancomycin every 12 hours for several weeks following hospital discharge. Facility policy required medications to be given as ordered and any withheld or late doses to be documented with a reason. Instead, the MAR showed vancomycin scheduled at non–12-hour intervals, multiple doses marked as not administered without any progress notes, and a total of 17 days when doses were given at intervals shorter or longer than every 12 hours. Later, when the dose was adjusted and continued per infectious disease consult, the order in the MAR ended prematurely, causing a scheduled PM dose not to be given because no active order was present. Nursing staff could not recall specific reasons for the missed doses and believed they were related to lab timing, while the DON was unaware of the extent of the missed or undocumented doses.
An LPN administered metoprolol to a resident who did not have an order for it; the medication belonged to the resident's roommate. Surveyor observation and MAR review confirmed the wrong-drug, wrong-resident error, and the DON identified it as a significant medication error. The resident had vascular dementia and severe cognitive impairment.
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