Recent CASPER data for Fiscal Year 2024 ranks deficiency F760, “Residents are Free of Significant Medication Errors,” as 25th and F759, “Free of Medication Error Rate of 5% or More,” as 27th. Let’s examine examples of these deficiencies along with an action plan based on best practices to avoid similar tags…

Review of Important Definitions (Appendix PP – SOM)

Medication Error is the observed or identified preparation or administration of medications or biologicals which is not in accordance with:

  1. The prescriber’s order;
  2. Manufacturer’s specifications (not recommendations) regarding the preparation and administration of the medication or biological; or
  3. Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils.

Significant Medication Error is defined as one which causes the resident discomfort or jeopardizes his or her health and safety. Significance may be subjective or relative depending on the individual situation and duration.

Determining Significance of Medication Errors

The significance of medication errors involves professional judgment, guided by three primary considerations:

  1. Resident Condition – The resident’s condition is an important factor to take into consideration. For example, a diuretic (fluid pill) erroneously administered to a dehydrated resident may have serious consequences, but if administered to a resident with a normal fluid balance may not. If the resident’s condition requires rigid control, such as with strict intake and output measurement, daily weights, or monitoring of lab values, a single missed or wrong dose can be highly significant;
  2. Drug Category – If the medication is from a category that usually requires the resident to be titrated to a specific blood level, a single medication error could alter that level and precipitate a reoccurrence of symptoms or toxicity. This is especially important with a medication that has a Narrow Therapeutic Index (NTI) (i.e., a medication in which the therapeutic dose is very close to the toxic dose). Examples of medications with NTI include: phenytoin (Dilantin), carbamazepine (Tegretol); warfarin (Coumadin); digoxin (Lanoxin); theophylline (TheoDur); lithium salts (Eskalith, Lithobid); and
  3. Frequency of Error – If an error is occurring repeatedly, there may be more reason to classify the error as significant. For example, if a resident’s medication was omitted several times, it may be appropriate, depending on considerations related to the resident’s condition and the relevant medication category, to classify that error as significant. (See Dose Reconciliation Technique to the Observation Technique below).

Examples of Medication Errors from actual CMS 2567 Statements of Deficiencies

F759 Medication Error Rate 5% or More

Failure to follow prescriber’s order:

      • Failure to hold an antihypertensive medication due to blood pressure reading.
      • Medication omitted due to not being available to administer.
      • Nurse did not offer the resident to rinse their mouth after administration of inhalers.
      • Nurse administered incorrect dose of House Stock Tylenol.

Failure to “Shake Well” or Mix a Suspension:

      • The nurse did not resuspend Humalog 75/25 insulin in the vial to ensure it was mixed correctly prior to drawing it up and administering.

Crushing Medications or opening capsules for which the manufacturer instructs to “do not crush”:

      • Nurse crushed Lamictal for administration. Medication instruction/warning on label – do not crush or chew.

Feeding Tube medication administration: (note: These 3 examples were cited together at a facility and resulted in Immediate Jeopardy)

      • Nurse poured Dilantin and Keppra into a Styrofoam cup with KCl diluted in 200 ml of water and administered them together via the GT.
      • Nurse failed to administer 50 ml of water prior to medication administration and did not administer 5 ml to 10 ml of water between each medication administered as per physician’s order. MAR which indicated to flush 50 ml of water via GT before and after medication administration and 5 ml to 10 ml in between medications.
      • Nurse prepared three medications for GT administration by crushing and diluting each with water. After she stated she had completed resident’s medication pass all three medicine cups noted with residual crushed medications. It was noted that some of the crushed tablets stuck to the bottom of the cup. Nurse stated she did not know how much of the medicine was left in the three medicine cups, but it seemed a lot. Nurse then disposed of them.

F760 Significant Medication Errors


      • Resident was to receive 3 doses of Dilaudid and 1 dose of Roxicodone. Nurse administered 1 dose of Dilaudid and 3 doses of Roxicodone. This occurred twice during the shift (12:00 and 4:00). The error was discovered while conducting controlled medication count at shift change.
      • Resident received another resident’s medications. The medications included 6 medications with black-box warnings and 2 controlled substances, and were administered by an agency nurse.
      • MAR indicated several missed doses of Eliquis, Furosemide and Metoprolol. MD had not been notified of medication errors. Resident diagnoses included chronic atrial fibrillation, chronic diastolic (congestive) heart failure, hypertension, and acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity.
      • While in the hospital, the residents’ provider from the mental health clinic gave a new order to start Invega Sustenna 1 ml IM every 28 days. The hospital gave the first dose on 9/7/23. The facility nurse entering the order put a start date of 9/19/23 and it was administered on that date.
      • Medications given more than 1hour after the prescribed time.
      • Resident had order for Tylenol 650mg 5 times per day – medication was scheduled for 12:00, 17:00, 19:00, 21:00 and 23:00. Multiple doses given only 2 hours apart. Medication is recommended to be given every 4-6 hours.
      • Observation of 82 opportunities resulted in 64 errors – 76% error rate. Errors were due to either omitted or late administration of medications. Omitted medications included sliding scale insulin. Some medications were administered more than 3 hours late.

Examples resulting in Immediate Jeopardy:

      • Resident with Alzheimer’s that frequently wanders into other resident rooms was sitting in a room that was not hers. Agency Nurse administered 10 u of Humalog without verifying resident’s identity. Resident was non diabetic. This deficiency was cited with scope/severity of J.
      • Resident was sitting in common area. Nurse failed to properly identify resident and administered the following medications to the wrong resident: Clozapine (antipsychotic medication), Melatonin (sleep aide), Simvastatin (cholesterol lowering medication), Trazadone (antidepressant), Amantadine (medication used to reduce uncontrolled movements), Keppra (anticonvulsant), Depakote (anticonvulsant), Diltiazem (cardiac medication to treat high blood pressure, chest pain).
      • During a medication observation the Nurse had seven residents’ medications pre-poured into paper medication cups located in the top drawer. Some of the paper medication cups were labeled with resident names, and some were not. Nurse was unable to identify the medications that were in each cup. In addition, to the pre-poured resident medications there was an unlabeled plastic medication cup with nine white round tablets that the Nurse identified as Tylenol 500 milligrams each.
      • Resident was given Narcan and transferred to the hospital after sustaining an unwitnessed fall and was noted to have potential opioid like sedation. Agency Nurse inadvertently administered roommate’s dose of methadone to this resident.

Steps for avoiding commonly cited medication errors

  1. Review and update medication policies/procedures to meet regulatory requirements and best practices.
  2. Educate licensed nurses (LNs) and certified medication technicians/aides (CMTs) on facility medication administration policies/procedures upon hire, including skills review and written exams.
  3. Ensure new agency LNs and CMTs receive orientation on medication pass policies/procedures.
  4. When reviewing medication administration skills, expand the basic 5 rights (Right resident – Right medication – Right dose – Right time – Right route) to include:
    1. Right assessment (of resident before administration of medication)
    2. Right evaluation (of resident after administration of medication)
    3. Right documentation
  5. Consult with your pharmacy to confirm that the Emergency Drug Kit contains frequently prescribed medications.
  6. Educate LNs and CMTs on protocols for unavailable medications.
  7. Ensure all necessary equipment and supplies are accessible during medication administration, including PPE, hand sanitizer, blood pressure monitors, alcohol swabs, etc.
  8. Include recent photos of residents in medication/treatment records for proper identification.
  9. Use flexible medication time codes to accommodate resident preferences and promote person-centered care.
  10. Provide clear instructions for G-Tube and IV flushes pre/post medication administration within the MAR.
  11. If the resident receiving medications via g-tube requires fluid regulation, then a physician’s order should include the amount of water to be used for the flushing between crushed medications and administration of medications
  12. Conduct annual competency assessments for medication administration, including skills and written tests.
  13. Integrate CMS’s Critical Pathway for medication administration observation (CMS-20056) into the QAPI process.


Join Proactive on July 9, 2024 for the informative webinar Immediate Jeopardy Risk: Medication Errors which is the next session in our 12-month webinar series Deconstructing IJ and High Risk Tags–designed to empower nursing home professionals with the knowledge and strategies needed to navigate the top risk areas associated with Immediate Jeopardy citations. Drawing from real-life examples of IJ citations, we’ll delve into actionable solutions to prevent these critical citations in facilities.

Contact Proactive to schedule an onsite mock survey visit. Our experienced team identifies potential deficiencies related to your systems, procedures and processes of care.


Written by Angie Hamer, RN, RAC-CT
Clinical Consultant

Was this article helpful? Access weekly insights when you sign up for our weekly newsletter!