The June 11 incident at Skyline Healthcare Center involved Resident 295, who receives medications through a surgically-placed stomach tube. Licensed vocational nurse LVN 1 crushed a Metoprolol Succinate ER tablet and poured the contents of a Duloxetine DR capsule into separate cups of water, federal inspectors observed at 9:09 AM.
Both medications are designed for extended release over hours. Crushing or opening them delivers the full dose immediately.
"Administering Metoprolol and Duloxetine as immediate release will provide larger doses to Resident 295 at once resulting in more immediate side effects like gastrointestinal irritation," LVN 1 told inspectors after being questioned about the preparation.
The nurse admitted knowing that sustained-release medications cannot be crushed and delayed-release capsules cannot be opened. She said crushing the tablet or opening the capsule "makes the release of the medication immediate instead of sustained."
LVN 1 was stopped before administering the improperly prepared medications.
The same morning brought a second medication error involving a different nurse and resident. At 9:06 AM, LVN 5 gave Resident 36 two crushed tablets of calcium 250 mg with vitamin D3 mixed in applesauce. The resident was prescribed only oyster shell calcium 500 mg tablets once daily for bone health.
"LVN 5 administered the wrong form of calcium, and that Resident 36 was not prescribed vitamin D3 by the physician," the nurse later acknowledged to inspectors.
A third medication failure involved a critical blood thinner. LVN 5 told Resident 11 that morning that apixaban wasn't available and would have to wait for pharmacy delivery. The resident had been prescribed the medication twice daily for deep vein thrombosis management since May 17.
Resident 11 was admitted to Skyline Healthcare with acute blood clots in both lower legs. Missing doses of the blood thinner could cause another clot "leading to hospitalization," LVN 5 told inspectors.
The Director of Nursing explained the stakes were even higher. Missing apixaban administration "can potentially cause thrombosis, which is critical because the blood is not properly thinned, and the clot can dislodge and travel to the heart and brain forming an embolism and causing a heart attack and stroke."
Medication refills should be ordered three to four days before the last dose to prevent unavailability, the director said. "Several licensed nurses failed to submit the apixaban 5 mg refill request timely to the pharmacy."
The facility's consultant pharmacist confirmed that neither the Metoprolol Succinate ER nor the Duloxetine DR should have been crushed or opened for feeding tube administration. Both medication orders required clarification for alternative forms that could safely go through the tube.
By June 13, the physician had changed both orders for Resident 295 to forms suitable for feeding tube administration, the Director of Nursing reported.
Resident 295 was admitted with high blood pressure and depression. The feeding tube medications were prescribed to manage both conditions. Resident 36 was admitted with age-related osteoporosis, requiring calcium supplementation to strengthen brittle bones.
The medication errors violated multiple facility policies. Skyline Healthcare's medication administration procedures require nurses to follow the "seven rights of medication" including the right medication and right method of administration. Nurses must compare medication labels with orders three times during preparation and administration.
The facility's crushing policy specifically prohibits altering sustained-release products and requires nurses to consult a "Do Not Crush" list and contact pharmacists when uncertain. If medications cannot be safely crushed, nurses must contact physicians for alternative orders.
Time-release tablets are "designed to release medication over a period of 8 to 12 hours" and "some formulations are designed to reduce gastric irritation," according to the facility's own guidelines.
The policy defines medication errors as doses that deviate from physician orders, including "incorrect preparation of dose," "incorrect administration technique," and "administration of medication without a valid order."
Inspectors found a separate insulin administration error involving Resident 6, where staff failed to rotate injection sites as required. The same-site injections can cause abnormal fat distribution and protein buildup in skin tissue.
The June 13 inspection documented multiple breakdowns in the medication system that the Director of Nursing said required "a more proactive approach and better communication to prevent this failure in the future."
None of the medication errors resulted in documented resident harm, but each created potential for serious adverse effects. The extended-release medications delivered as immediate doses could have caused dangerous side effects. The missing blood thinner left a clot patient vulnerable to life-threatening complications.
Resident 11's medication administration record showed no documentation for the missed 9 AM apixaban dose on June 11, confirming the gap in critical anticoagulation therapy for someone admitted specifically for blood clots in both legs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skyline Healthcare Center - La from 2024-06-13 including all violations, facility responses, and corrective action plans.
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