A resident with severe cognitive impairment received another resident’s medications after a med pass error, and later was given Valbenazine without documented TD or another indication. Staff could not explain why the drug was started, the behavior committee notes lacked supporting documentation, and the record later stated the medication had been ordered for another resident due to a transcription error.
A resident with amputations and intact cognition received oxycodone under an order that was entered into the EMR as TID even though the handwritten order and narcotic sign-out sheet reflected BID. The MAR and narcotic record showed multiple doses given at intervals that did not match a 12-hour schedule, and the DON confirmed the order had been incorrectly transcribed and the doses were not 12 hours apart.
An LPN prepared PRN oxycodone for a cognitively intact resident with chronic pain syndrome and osteomyelitis, despite the MAR showing the last dose had been given only a few hours earlier. The LPN recognized it was too early only after reviewing the MAR when questioned, and the DON confirmed staff may rely on an EMR Y tab and could potentially give the medication before seeing the PRN timing alert.
A resident with lymphoma, anemia, neutropenia, and worsening dysphagia received oral etoposide after oncology had documented that the medication was to be stopped. The MAR showed the chemotherapy was administered despite the stop order, and the resident developed nausea, dizziness, weakness, and worsening swallowing difficulty before being sent to the ER, where he was found to be profoundly more anemic and required a blood transfusion. Facility staff later stated the resident should not have received the medication and that the incoming paperwork had not been reviewed by a nurse.
A resident with dysphagia, spastic quadriplegic cerebral palsy, epilepsy, and severe cognitive impairment received phenytoin via PEG tube after an LPN crushed the tablet and mixed it in water, but the medication was not completely dissolved. The surveyor observed undissolved particles remaining in the cup before and after it was rinsed and administered, and the DON confirmed that crushed medications must be fully dissolved before PEG tube administration.
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 type 2 DM and edema had multiple medication administration errors. The MAR showed one instance where BG was 404 and only 4 units of insulin lispro were given instead of the ordered 5 units, and several instances where the resident’s weight increased by 3 lb or more overnight but PRN furosemide was not administered as ordered. An RN and the DON acknowledged the orders and that the PRN medication should have been given when the weight gain threshold was met.
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.
Improper Administration of Delayed Release Medications: Two residents received medications in altered form without documented pharmacy review or appropriate authorization. An RN crushed a DR tablet and opened DR capsules for one resident, and opened a DR capsule for another resident, despite general nursing notes allowing meds to be crushed and no record showing review of whether the DR medications could be altered. The DON confirmed the pharmacy review had not been completed before administration.
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.
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