Crushing of Do-Not-Crush Medications Leads to Elevated Medication Error Rate
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 4 errors out of 34 opportunities, resulting in an 11.76% error rate. The affected resident had an admission date of 09/25/18 and diagnoses including paroxysmal atrial fibrillation, polyosteoarthritis, and gastro-esophageal reflux disease (GERD) without esophagitis. Physician orders for this resident included Metoprolol Succinate ER 25 mg once daily and Metoprolol Succinate ER 50 mg once daily (for a total of 75 mg daily), Pantoprazole Sodium delayed release 20 mg once daily, and Tylenol eight hour arthritis pain ER 650 mg twice daily. There was also a standing order allowing nursing to crush medications or open capsules and mix them in food or drink unless the medications were delayed release/ER, enteric coated, or listed on the facility’s do not crush list. During observation and interview on 04/22/26 at 8:00 A.M., an LPN crushed the resident’s Tylenol eight hour arthritis pain ER 650 mg, Metoprolol Succinate ER 25 mg, Metoprolol Succinate ER 50 mg, and Pantoprazole Sodium delayed release 20 mg and administered all four crushed medications in pudding. The LPN confirmed that she had crushed and administered these four medications in this manner. Review of the facility’s do not crush list showed that all four of these medications—Tylenol eight hour arthritis pain ER 650 mg, Metoprolol Succinate ER 25 mg and 50 mg tablets, and Pantoprazole Sodium delayed release 20 mg—were specifically listed as medications that were not to be crushed, directly leading to the identified medication errors and the elevated medication error rate.
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 identified an 11.1% medication error rate when an LPN did not administer a resident’s ordered nifedipine ER dose because it was not available in the cart or pyxis, and proceeded with the rest of the medications. In a separate instance, an RN administered furosemide despite the order having been discontinued and gave magnesium oxide instead of the ordered SlowMag, explaining that he relied on scanning multi-drug packets rather than individually verifying each medication against the MAR, and knowingly substituted magnesium oxide when SlowMag was unavailable.
The facility failed to keep its medication error rate below 5% when a resident with dementia, COPD, diabetes, and depression did not receive ordered doses of Singulair and calcium/vitamin D3 because the medications were not available at the time of administration. An RN attempted to pass the morning medications but was unable to administer these two ordered drugs, and later confirmed their unavailability, resulting in two errors out of 33 medication opportunities and an overall error rate of 6.06%.
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 that the facility exceeded the acceptable medication error rate when, during a morning med pass, an RN was unable to administer an ordered dose of Synthroid to a resident with diabetes, hypothyroidism, and hypertension because it was not available in the med cart or emergency box, and also failed to remove a scheduled dose of glipizide from the medication card until prompted by the surveyor. These two omission errors, identified during observation and confirmed in staff interviews and record review, resulted in a 7% medication error rate for 28 observed medication opportunities.
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 and Unavailable Ordered Medications
Penalty
Summary
The deficiency involves failure to ensure medications were administered in accordance with physician orders, resulting in three medication errors out of 26 opportunities and an 11.1% medication error rate. In one instance, an LPN preparing a resident’s morning medications found that nifedipine ER 60 mg, ordered once daily since 02/13/25, was not available in the medication cart or the pyxis machine. The LPN stated she would contact the pharmacy, documented that the nifedipine was unavailable for administration, and proceeded to offer the remainder of the resident’s medications without administering the ordered nifedipine dose. In another instance, an RN administering medications to a different resident gave one tablet of furosemide 40 mg and one tablet of magnesium oxide 400 mg. Review of the resident’s orders showed there was no current order for furosemide, as the most recent order had been discontinued on 12/19/24, and that the resident instead had an active order for two SlowMag Muscle/Heart delayed-release tablets (magnesium chloride–calcium carbonate) twice daily rather than magnesium oxide. The RN reported that he did not individually check each medication in the multi-drug packets, relying instead on scanning the barcodes on the packets and only looking for medications flagged as missing. He further stated he administered magnesium oxide because SlowMag was not available and confirmed he knew the two medications were not the same. The facility’s medication administration policy required medications to be given only as prescribed, adherence to the five rights of medication administration, and reading the medication label three times while comparing it to the MAR.
Medication Error Rate Exceeded Due to Unavailable Ordered Medications
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 6.06% (two errors out of 33 medication opportunities) during a complaint investigation. Resident #15, admitted on 01/01/21 with dementia, chronic obstructive pulmonary disease, diabetes mellitus, and depression, was cognitively impaired and dependent on staff for activities of daily living per the 03/10/26 MDS assessment. Physician orders dated 02/06/26 directed that the resident receive Singulair 10 mg daily and calcium/vitamin D3 500 mg/5 mcg every morning and at bedtime. On 04/28/26 at 8:24 A.M., observation of medication administration by RN #105 showed that neither Singulair nor calcium/vitamin D3 was given because the medications were not available for administration. In an interview at 8:34 A.M. the same day, RN #105 confirmed that these ordered medications were not available to be administered as prescribed, contributing to the identified medication error rate above 5%.
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 Omission Errors Resulting in Elevated Medication Error Rate
Penalty
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.
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