Significant Medication Error When Wrong Resident Received Another Resident’s Medications
Summary
The deficiency involves a failure to ensure that a resident was free from significant medication errors when an LPN administered another resident's medications. Facility policy required that medications be administered safely and as prescribed, including verifying the resident's identity before administration using methods such as checking an identification band, reviewing a photograph on the medical record, and, if necessary, confirming identity with other staff. The policy also required the person administering medications to check the label three times to verify the right resident, medication, dosage, time, and route, and prohibited administering medications ordered for one resident to another. Despite these requirements, the LPN pre-poured medications for more than one resident at a time and did not correctly verify the resident's identity before administration. The resident who received the wrong medications, identified as R2, had been admitted with diagnoses including cognitive communication deficit, dementia with mild anxiety, atrial fibrillation, dysphagia, and major depressive disorder. Another resident, identified as R3, had diagnoses including heart failure, high blood pressure, chronic pain syndrome, and lumbar spondylosis, and had active orders for multiple medications: oxycodone 30 mg three times daily, amlodipine 5 mg (two tablets once daily), losartan 50 mg twice daily, dofetilide 250 mcg twice daily, gabapentin 600 mg four times daily, and metoprolol 50 mg once daily. R2 did not have physician orders for these medications. On the morning of the incident, the LPN labeled a medication cup with a resident's name, poured medications into the cup, mixed whole pills in pudding, and administered them to R2 in her room. The LPN later discovered that R2's medication cup was still on the cart and realized that the medications given to R2 were actually those prescribed for R3. Following the administration error, staff documented that R2 had received oxycodone 30 mg, amlodipine 5 mg, losartan 50 mg, dofetilide 250 mcg (also documented once as 520 mcg), gabapentin 600 mg, and metoprolol 50 mg, none of which were ordered for her. Progress notes and vital sign records showed that R2 subsequently experienced low blood pressure and slow heart rate, with multiple blood pressure readings in the 70s and 80s systolic and 40s diastolic, and heart rates in the 40s and 50s. A nurse practitioner assessed R2 shortly after the error and initially noted no acute distress, but within an hour R2 became symptomatic. Later documentation indicated that R2 was transferred to the hospital, where she was evaluated for somnolence, hypotension, bradycardia, and hypoxia after receiving the incorrect medications. Hospital records described that she required interventions including IV fluids, naloxone, atropine, and vasoactive medications due to persistent hypotension over several days, and she was diagnosed with hypotension due to drugs, drug overdose (accidental or unintentional), confusion caused by a drug, bradycardia, respiratory insufficiency, sepsis with acute hypoxic respiratory failure, and pneumonia. The state survey agency determined that the facility's non-compliance with pharmacy services requirements caused or was likely to cause serious injury, harm, impairment, or death, and cited the facility at F760.
Removal Plan
- The Administrator notified the Medical Director of the Immediate Jeopardy.
- R2 was assessed by the Nurse Practitioner, and new orders were written for vital signs every 30 minutes and Midodrine stat.
- R2 was sent to the emergency department for a higher level of care.
- The Assistant Director of Nursing began the investigation into the medication error.
- The Assistant Director of Nursing counseled LPN1 related to the medication error and failure to follow the five rights of medication pass, including prepulling medication that resulted in the medication error; the licensed nurse was placed on a process improvement plan.
- The Assistant Director of Nursing provided 1:1 education with LPN1 related to types of medication errors, causes, and prevention.
- The Assistant Director of Nursing began a medication pass in-service related to the 5 rights of medication administration.
- The Assistant Director of Nursing or designee began education with the licensed nurses on the 5 rights of medication pass and medication administration.
- The Assistant Director of Nursing or designee began education on the medication administration policy to include how to verify the medications are correct for all licensed nurses on or before their next scheduled shift.
- The Assistant Director of Nursing or designee began competency checks on medication pass on all licensed nurses.
- The Administrator, the Director of Nursing, and the Assistant Director were re-educated on Medication Pass, including medication errors, by the Regional Assistant Director of Clinical Services.
- The Director of Nursing completed a review of hospitalizations to determine if any were related to medication error.
- The Director of Nursing completed a medication error review to ensure proper documentation, appropriate corrective action, and reporting compliance.
- Nurse management will randomly select each nurse daily to observe medication passes for 7 days, then weekly for 4 weeks, then monthly for 2 months.
- The nurse involved in the deficiency will complete medication pass competency daily for 7 days, weekly for 4 weeks, monthly for 2 months, and quarterly for 2.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Staff failed to administer multiple ordered medications, including antihypertensives, carbidopa-levodopa, and carvedilol, to three residents despite the drugs being available in the facility. One resident with severe cognitive impairment and a history of markedly elevated BP missed several doses of multiple antihypertensive agents shortly after admission, while BP readings remained elevated. Another resident with Parkinson’s disease and severe cognitive impairment did not receive several scheduled doses of carbidopa-levodopa, with no documentation of refusal. A third cognitively intact resident with acute systolic heart failure and hypertension did not receive an evening dose of carvedilol even though vital signs were within ordered parameters and the medication was on hand. The DON confirmed that these medications were not administered per physician orders, contrary to facility policies requiring administration as ordered and use of on-hand stock when needed.
A resident with type 2 DM and daily insulin orders, including sliding-scale lispro and scheduled Lantus, received insulin injections from an LPN who did not prime either insulin pen before administration. After confirming the resident’s elevated blood glucose and full meal intake, the LPN dialed specific doses on both lispro and Lantus pens and administered them without priming. In a later interview, the LPN acknowledged not priming the pens, despite manufacturer instructions requiring priming before each injection to remove air and ensure proper pen function.
A resident with small B-cell lymphoma and intact cognition had physician orders for nightly Ibrutinib capsules, including a specified hold period. Review of MARs showed that several doses were not administered on multiple days outside the ordered hold period, and there was no documentation in the record explaining the missed doses. The DON later reported that the pharmacy did not have the medication and believed the oncologist had stopped it, but this was not supported by any written orders or documentation, resulting in a significant medication error.
The facility failed to prevent significant medication errors for four residents. One resident returned from an outside visit with new orders for an antibiotic that was never documented as administered. Another resident with an indwelling catheter had a positive urine culture for pseudomonas and a physician order for Bactrim DS, but the MAR showed no doses given. A third resident with breast cancer had an oncology prescription for Verzenio that was not acted upon for several weeks despite the resident reporting she should be on a new cancer medication and staff contacting the oncology office without documented follow-up. A fourth resident with DM received Humalog insulin doses on several occasions when blood glucose values were below the ordered parameters, as confirmed by an RN.
A resident with severe cognitive impairment and multiple medical conditions, including infection and type II DM, had physician orders for Seroquel via J-tube three times daily and ciprofloxacin via J-tube every 12 hours. Audit review showed that the 9:00 A.M. doses of both medications were repeatedly administered several hours late over multiple days, outside the facility’s stated one-hour-before/after administration window, as confirmed by the DON. Resident Council minutes also reflected complaints about late medications, and facility policy required immediate documentation after medication administration.
Surveyors found that the facility failed to prevent significant medication errors, including administration of morphine and lorazepam without active orders to a hospice resident with severe psychiatric and neurological conditions, as documented in narcotic logs, hospice notes, and electronic messages. Other residents with glaucoma, heart failure, chronic pain, epilepsy, hemiplegia, and vascular dementia missed multiple scheduled 9 p.m. doses of ophthalmic agents, an anticoagulant (Eliquis), and an antiepileptic (topiramate), as shown on MARs and confirmed by a regional clinical director. These actions and omissions occurred despite a facility policy requiring verification of the right resident, medication, dose, time, and route before administration.
Failure to Administer Available Ordered Medications as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically related to not administering ordered medications despite their availability. One resident with type 2 diabetes, chronic kidney disease, hypertension, and hypokalemia was admitted with a history of chronically elevated systolic blood pressure up to the 190s and had multiple antihypertensive medications ordered from the hospital, including lisinopril, amlodipine, atenolol, hydralazine, and hydrochlorothiazide. Facility physician orders mirrored these medications, but the evening doses of atenolol and hydralazine on the day of admission were not given, and the following day the resident did not receive hydrochlorothiazide, lisinopril, or the morning doses of amlodipine, hydralazine, and atenolol. Blood pressure readings during this period showed elevated values, including 193/99, and a late-entry nursing note documented that the resident’s blood pressure was elevated and that medications had just arrived from the pharmacy, even though the facility’s Medication Inventory on Hand report showed all ordered antihypertensives were available. Another resident with Parkinson’s disease with dyskinesia, hypertension, atrial fibrillation, and gait abnormalities had a hospital order for carbidopa-levodopa 25/100 mg three times daily. The facility’s physician orders continued carbidopa-levodopa three times daily, though it was incorrectly indicated for convulsions. The MAR showed that this resident did not receive the evening and bedtime doses of carbidopa-levodopa on the first day and did not receive the bedtime dose the following day, despite the medication being available per the Medication Inventory on Hand report. Nursing documentation for those days did not indicate that the resident refused the medication, and the DON confirmed that the medication was not administered as ordered. A third resident with acute systolic heart failure, acute pulmonary edema, cardiomegaly, and hypertension was discharged from the hospital with an order for carvedilol 6.25 mg twice daily. The facility’s physician order matched this, including parameters to hold the dose if systolic blood pressure was less than 100 or pulse was less than 60. On the day of admission, the resident’s blood pressure and heart rate were within the parameters for administration, but the evening dose of carvedilol was not given according to the MAR. Nursing notes did not document any refusal of the medication, and the Medication Inventory on Hand report showed carvedilol was available. The DON verified that this resident’s medication was also not administered per physician orders. Facility policies required medications to be administered according to written physician orders and directed staff to use on-hand medication supplies when pharmacy medications were not yet available.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The deficiency involves the failure to ensure a resident was free from significant medication errors when insulin pens were not primed according to manufacturer instructions prior to administration. The resident had type 2 diabetes mellitus, was moderately cognitively impaired, and had physician orders for multiple insulin regimens, including insulin lispro via sliding scale, a scheduled daily dose of insulin lispro, and a morning dose of Lantus. The resident’s care plan identified a risk for complications and blood glucose fluctuations related to diabetes and insulin use, with an intervention to administer insulin as ordered. On the day of observation, an LPN checked the resident’s blood sugar, which was 332, and confirmed the resident had eaten 100% of breakfast. The LPN then removed the resident’s lispro and Lantus insulin pens from the medication cart, dialed the lispro pen to 34 units and the Lantus pen to 50 units, and did not prime either pen before dialing in the doses. The LPN proceeded to administer both insulin injections without priming. In a subsequent interview, the LPN confirmed that she had not primed the insulin pens prior to administration. Manufacturer instructions for the KwikPen specified that the pen must be primed before each injection to remove air and ensure proper function, outlining specific steps to select 2 units, hold the pen needle-up, tap to collect air bubbles, and push the dose knob until insulin is seen at the needle tip before dialing the prescribed dose.
Failure to Administer Ordered Cancer Medication and Document Missed Doses
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when ordered doses of Ibrutinib, a targeted cancer medication for lymphoma, were not administered and lacked documented justification. The resident, who had intact cognition and diagnoses including small B-cell lymphoma, difficulty in walking, need for assistance with personal care, and cardiomegaly, was admitted and later discharged in January. Physician orders directed Ibrutinib 140 mg, three capsules by mouth at bedtime, with one order active from early January until mid-January and a subsequent order active from mid-January with a specified hold period and later discontinuation. Review of the MARs showed that Ibrutinib was not given on multiple dates outside the ordered hold period, and the medical record contained no evidence explaining these missed doses. In an interview, the DON stated that the pharmacy did not have the medication available and that she believed the oncologist had stopped it, but she confirmed that this information was not documented in the medical record, contrary to the facility’s policy requiring medications to be administered in accordance with written prescriber orders. This deficiency was cited as non-compliance under Complaint Numbers 2786595 and 2704190.
Failure to Prevent Significant Medication Errors for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, affecting four residents reviewed for medication administration. One resident with cerebral infarction, left hemiplegia, mood disorder, HTN, and epilepsy was seen at Urgent Care for a widespread rash and excoriation, where Keflex and Diflucan were ordered for a fungal skin infection and candidal intertrigo. The resident returned to the facility with these new orders, but the medical record contained no documentation that Keflex was ever administered as ordered, which was confirmed by the DON. Another resident with DM, Down’s syndrome, Hirschsprung’s disease, morbid obesity, and an indwelling catheter had purulent and grey-green drainage from the catheter site and complained of pain with urination. A UA with reflex culture was ordered, and the culture later showed greater than 100,000 pseudomonas, with a handwritten physician order on the report for Bactrim DS twice daily for seven days. Review of the MAR for that month showed no documentation that Bactrim was administered, and the MDS nurse confirmed the antibiotic was not given as ordered for the urinary tract infection. A third resident with breast cancer, HTN, major depressive disorder, and osteoarthritis had an oncology order and prescription for Verzenio 150 mg PO twice daily for cancer treatment. The resident later told nursing staff she was supposed to be on a new oncology medication, and the oncology office was called with a message left, but there was no documented follow-up or clarification. Subsequent oncology documentation showed the resident still had not received Verzenio, and the drug was not ordered by the facility physician or administered until several weeks after the original prescription date. A fourth resident with acute and chronic respiratory failure with hypoxia, type 2 DM with hyperglycemia, and CKD stage 3 had insulin orders specifying administration only when blood sugar exceeded certain thresholds, yet insulin doses of 18 units and 2 units were administered on multiple dates when blood glucose values were below the ordered parameters. A nurse interview verified that insulin had been given outside the prescribed parameters.
Failure to Administer Medications in a Safe and Timely Manner
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in a safe and timely manner for one resident. The resident was admitted for aftercare following explantation of a hip joint prosthesis and had diagnoses including infection and inflammatory reaction due to orthopedic prosthetic devices, acute embolism and thrombosis of deep veins, type II diabetes mellitus, and lumbosacral radiculopathy. The most recent MDS assessment documented that the resident was severely cognitively impaired, rarely or never understood, had no behaviors, and did not reject care. Physician orders included Seroquel (quetiapine fumarate) 12.5 mg via J-tube three times daily for bipolar disorder and ciprofloxacin 750 mg via J-tube every 12 hours for infection. Review of the medication administration audit report showed that on three consecutive days, the 9:00 A.M. doses of Seroquel and ciprofloxacin were administered several hours late: at 12:59 P.M., 12:17 P.M., and 12:32 P.M., respectively. In interview, the DON stated that nurses are expected to administer medications within one hour before or one hour after the scheduled time and confirmed that these medications were given outside the facility’s parameters for safe medication administration. Resident Council minutes from February and March documented resident complaints about medications being administered late. The facility’s policy on documentation of medication administration required that administration be documented immediately after it is given.
Failure to Prevent Significant Medication Errors and Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, including administering controlled substances without active orders and failing to administer ordered medications on multiple occasions. One resident with severe psychiatric and neurological diagnoses had PRN orders for morphine sulfate and lorazepam that were discontinued early in the month, with no subsequent active orders. Despite this, controlled substance records showed lorazepam doses documented on two dates later in the month and morphine doses documented on three dates, including the day of the resident’s death, all without active physician orders. Entries on the narcotic logs were illegible. Hospice documentation indicated that a hospice RN visited the resident due to lethargy and minimal responsiveness, discussed medication administration with an LPN, and noted that lorazepam and morphine were administered during the visit. Electronic triage messages showed the LPN informed the hospice NP that the lorazepam order was not active, requested that it be reinstated and increased, and acknowledged that the resident had not been receiving the medication, yet also indicated that medications were on hand and had been given on specific dates. Additional deficiencies were identified for a resident with glaucoma and related eye pressure issues whose multiple ophthalmic medications and an oral medication for high eye pressure were ordered for administration at 9:00 P.M. and twice daily. Review of the MAR for this resident showed that several 9:00 P.M. doses of Latanoprost, Rhopressa, Brimonidine Tartrate, Dorzolamide-Timolol, and Methazolamide were not administered on multiple dates in the same month. The Regional Clinical Director confirmed that these medications were not given at the ordered times on the identified dates. The resident was documented as cognitively intact on the MDS assessment. A further deficiency involved a cognitively intact resident with hypertensive heart disease with heart failure, intervertebral disc degeneration, and chronic pain syndrome who had an order for Eliquis 5 mg at 9:00 P.M. The MAR showed that this anticoagulant was not administered on multiple specified 9:00 P.M. doses in the same month, and the Regional Clinical Director verified the missed doses. Another resident with hemiplegia, epileptic seizures, vascular dementia, and severe cognitive impairment had a long-standing order for topiramate 50 mg daily at 9:00 P.M. for epilepsy. The MAR revealed that the 9:00 P.M. doses of topiramate were not administered on multiple dates in the same month, and the Regional Clinical Director confirmed these missed doses. The facility’s medication administration policy required staff to verify the right resident, medication, dosage, time, and route before administration, but the documented omissions and administration of medications without active orders demonstrate that this process was not consistently followed.
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