Medication Omission Errors Resulting in Elevated Medication Error Rate
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 28 medication administration opportunities and two medication omission errors, resulting in a 7% error rate. The deficiency involved one resident who had been admitted with diagnoses including type 2 diabetes mellitus, hypothyroidism, and hypertension. Physician orders for this resident included Synthroid 50 mcg once daily and glipizide 10 mg every morning. During a morning medication pass, an RN was observed attempting to administer the resident’s medications and was unable to locate the ordered Synthroid in the medication cart or emergency box, resulting in a missed dose. During the same observation, the RN pulled the resident’s glipizide card from the medication drawer but did not remove the scheduled dose before returning the card to the drawer. Before the RN administered the morning medications, the surveyor intervened and questioned whether the glipizide dose had been removed, at which point the RN confirmed it had not and then retrieved the medication for administration. In subsequent interviews, the RN confirmed that Synthroid was not available for administration and that glipizide was only given after the surveyor’s intervention. The DON acknowledged that these two omission errors for Synthroid and glipizide, out of 28 opportunities, resulted in a 7% medication error rate for the observed medication pass.
Penalty
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Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors observed two medication administration errors that caused the facility’s medication error rate to exceed 5%. In one case, an LPN administered insulin using a pen device to a resident with diabetes without priming the pen as required by the manufacturer’s instructions. In another case, an LPN measured a resident’s ordered 17 g dose of MiraLAX by filling the product cap only partway instead of to the top rim as specified on the container, then administered the inaccurately measured dose. These actions resulted in a calculated medication error rate of 7.14% during the survey.
Surveyors observed an LPN administering insulin to a resident with type 2 DM and daily insulin orders without priming either the lispro or Lantus insulin pens before dialing and giving the doses, contrary to manufacturer instructions requiring priming before each injection. The resident’s blood sugar was elevated, and the LPN confirmed the pens were not primed. This contributed to 2 errors in 25 opportunities, resulting in a medication error rate above the 5% threshold.
Surveyors found the facility exceeded the acceptable medication error rate when an LPN administered multiple ophthalmic medications to a resident with complex medical conditions and moderate cognitive impairment. The LPN instilled Atropine and Prednisolone, which were ordered for only one eye, into both eyes, and also gave Brimonidine and Brinzolamide in both eyes without clarifying an incomplete order for Brinzolamide. The LPN did not observe the required time intervals between different eye drops as specified by manufacturer instructions and facility policy, contributing to four medication errors during a single medication pass.
Surveyors found that the facility’s medication error rate exceeded 5% when two residents with type 2 DM did not receive insulin as ordered. For one resident, an LPN administered eye drops and oral medications but held the ordered morning Lantus dose without resident refusal, provider notification, or any order parameters to hold the insulin, despite facility policy requiring prescriber contact if a dose is believed inappropriate. For another resident, an RN administered Lantus using a pen device without performing the required priming/safety test steps outlined in the manufacturer’s instructions, instead only checking for air bubbles before injection. These two insulin-related errors, out of 34 observed opportunities, resulted in a 5.8% medication error rate.
A resident with severe cognitive impairment and multiple chronic conditions, including Alzheimer’s disease, diabetes with polyneuropathy, psychotic disorder, hypertension, and severe protein-calorie malnutrition, had physician orders for Preservision AREDS, Protonix, and Refresh Tears. During a medication pass, an LPN did not administer these medications because they were unavailable, which was confirmed by MAR review showing they were not given as ordered. With 28 opportunities for medication administration and three omissions, the facility’s medication error rate was 10.7%, exceeding the 5% threshold, contrary to the facility’s medication administration policy.
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Medication Administration Errors Result in Exceeding 5% Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors in 28 medication administration opportunities, resulting in a 7.14% error rate. For one resident with diabetes mellitus who was cognitively intact and received insulin injections daily, the physician’s order directed administration of insulin aspart 23 units SQ with meals. During observation of a medication pass, an LPN removed the insulin aspart pen from the cart, dialed the pen directly to 23 units, attached the needle, and administered the dose without priming the pen. The LPN confirmed she did not prime the pen and acknowledged that her usual practice would be to prime the pen, then dial the required dose, then place the needle on the pen. Manufacturer instructions for the KwikPen specified that the pen must be primed before each injection by selecting 2 units, holding the pen needle-up, tapping to move air bubbles, and pushing the dose knob until insulin is seen at the needle tip before dialing the prescribed dose. In a separate incident, another resident with Crohn’s disease, diverticulosis, constipation, severe cognitive impairment, and frequent bowel incontinence had a physician’s order for MiraLAX powder 17 g PO once daily. During an observed medication administration, an LPN measured the MiraLAX powder by filling the product cap only to just under the very bottom line inside the lid, then poured this amount into water for administration. When asked to read the product instructions, the LPN reviewed the MiraLAX container, which stated that the bottle cap is a measuring cup designed to contain 17 g when filled to the top rim. The LPN confirmed that the MiraLAX had not been measured according to the manufacturer’s instructions. These two observed medication administration errors formed the basis of the cited deficiency under the referenced complaint investigation.
Failure to Prime Insulin Pens Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 2 errors in 25 medication administration opportunities, resulting in an 8% error rate. The affected resident had type 2 diabetes mellitus and was moderately cognitively impaired, with physician orders for multiple insulin regimens, including insulin lispro per sliding scale, a fixed daily dose of insulin lispro with instructions to adjust based on meal intake, and a daily morning dose of Lantus. The resident’s care plan identified risk for complications and blood glucose fluctuations related to diabetes and insulin use, with an intervention to administer insulin as ordered. During observation, an LPN checked the resident’s blood sugar, which was 332, and confirmed the resident had eaten 100% of breakfast. The LPN then prepared the resident’s insulin by dialing 34 units on the lispro pen and 50 units on the Lantus pen without priming either pen before setting the doses. The LPN proceeded to administer both insulin injections without performing the priming step. In a subsequent interview, the LPN confirmed that she did not prime the insulin pens prior to dialing in and administering the doses. Manufacturer instructions for the KwikPen, reviewed by surveyors, specified that the pen must be primed before each injection to remove air and ensure proper function, indicating that the observed practice did not follow the manufacturer’s directions for use.
Medication Error Rate Exceeded Due to Improper Ophthalmic Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 4 errors in 34 opportunities, resulting in an 11.76% error rate. The deficiency involved one resident who was admitted with diagnoses including respiratory failure, malnutrition, embolism of the right upper extremity and bilateral lower extremities, anemia, and hypotension, and who had moderate cognitive impairment and required substantial assistance with activities of daily living. The resident’s March physician orders included multiple ophthalmic medications: Brinzolamide 1% eye drops ordered as one drop twice a day without specifying which eye(s); Brimonidine 0.2% eye drops ordered as one drop in each eye twice a day; Atropine 1% eye drops ordered as one drop in the right eye; and Prednisolone Acetate 1% eye drops ordered for the right eye once daily. During observed medication administration, an LPN prepared the resident’s morning eye medications and then administered Atropine, Prednisolone, Brimonidine, and Brinzolamide in both eyes in rapid succession, without waiting the required interval between different eye drops. The LPN confirmed she did not wait five minutes between administering the eye drops, despite facility policy and manufacturer instructions requiring a waiting period between multiple ophthalmic products. She also acknowledged administering Atropine, Prednisolone, and Brinzolamide in both eyes because the resident requested drops in both eyes, even though the orders for Atropine and Prednisolone specified the right eye only and the Brinzolamide order lacked clarification regarding which eye(s) to treat. The Brinzolamide order was not clarified with the physician, contrary to facility policy requiring clarification of incomplete or questionable medication orders. Manufacturer instructions for all four medications specified waiting at least five minutes between drops (and ten minutes for Brinzolamide when used with another eye medication), which was not followed.
Medication Error Rate Exceeded 5% During Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 34 opportunities, resulting in a 5.8% error rate. For one resident with type 2 diabetes mellitus and multiple comorbidities, the care plan included administration of insulin as ordered. The physician’s order specified Lantus 18 units subcutaneously in the morning. During a morning medication pass, an LPN administered the resident’s eye drops and oral medications but held the ordered Lantus dose, despite the resident not refusing the injection and there being no parameters in the order to hold it. The LPN later confirmed she did not contact the provider and that the resident’s blood sugar that morning was 97, and facility policy required contacting the prescriber if a dosage was believed to be inappropriate or excessive. For a second resident with type 2 diabetes mellitus and other diagnoses including dementia, depression, and chronic kidney disease, the care plan identified risk for hyper/hypoglycemia with an intervention to administer medications as ordered. The physician’s order specified Lantus SoloStar 10 units subcutaneously in the morning. During observation of a medication pass, an RN prepared the Lantus pen by attaching a needle and dialing the dose to 10 units but administered the injection without priming the pen. In interview, the RN stated she checked the pen for air bubbles but did not know any other way of priming it. The manufacturer’s instructions for the Lantus SoloStar pen require performing a safety test before each injection, including selecting 2 units, removing caps, holding the pen needle-up, tapping to move air bubbles, and pressing the injection button to ensure insulin comes out and the dose window returns to 0. These observed deviations from ordered insulin administration and manufacturer instructions contributed to the calculated medication error rate above 5%.
Medication Omission Leads to Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all physician-ordered medications were administered to a resident, resulting in a medication error rate above 5 percent. Resident #70, admitted on 04/08/16, had multiple diagnoses including Alzheimer’s disease, diabetes mellitus with diabetic polyneuropathy, psychotic disorder with delusions, hypertension, severe protein calorie malnutrition, and muscle weakness. A quarterly MDS dated 01/29/26 documented severely impaired cognition with a BIMS score of 03. The resident’s care plan, dated 02/17/26, identified risk for alteration in mood related to anxiety, dementia, and depression, with an intervention to administer medications as ordered. Physician orders included Preservision AREDS 2 mg daily for macular degeneration, Protonix 40 mg daily for GERD, and Refresh Tears eye drops four times daily for dry eyes. On 02/23/26 at 9:05 A.M., an observation of LPN #362 preparing medications for Resident #70 showed that the LPN did not administer Preservision AREDS, Protonix, or Refresh Tears because the medications were unavailable. Concurrent interview with the LPN confirmed these medications would not be given at that time due to unavailability. Review of the February MAR showed these three medications were not administered on 02/23/26 for that reason. Based on 28 opportunities for medication administration and three omissions, the medication error rate was calculated at 10.7%. Review of the facility’s “Administering Medications” policy, last reviewed 04/28/25, stated that medications must be administered in accordance with orders, including required time frames. This deficiency was investigated under Complaint Numbers 2629125 and 1266301.
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