Medication Errors in Nursing Homes 

Wrong drug, wrong dose, missed doses, and antipsychotics given to keep residents quiet are the medication errors that injure nursing home residents most, and a nursing home medication error lawyer who is a nurse reads the medication administration record against the orders to find them.

A nursing home resident takes an average of eight or more medications a day. Every dose is supposed to be ordered by a physician, verified by a pharmacist, and recorded by the nurse who gave it. Errors happen at each step: an order transcribed wrong, a drug given to the wrong resident, a blood thinner continued after it was stopped, insulin given without a glucose check, a dose skipped because the shift was short and nobody charted it. Some errors are deliberate. Antipsychotic drugs given to a resident with dementia who has no psychiatric diagnosis, to make the resident easier to manage, are a chemical restraint and a form of abuse under California law.

Errors We See Most

• Wrong drug or wrong dose

• Medication given to the wrong resident

• Doses missed or given late, especially pain medication and insulin

• Blood thinners, sedatives, and opioids given without required monitoring

• Antipsychotics and sedatives used as chemical restraints without consent

• Drug interactions nobody checked

• Medications continued after the physician discontinued them

What We Investigate

• The medication administration record against the physician orders, dose by dose

• Pharmacy consultant reviews and whether their recommendations were followed

• Lab monitoring for drugs that require it

• Informed consent for psychotropic medications (Health and Safety Code section 1418.9)

• Staffing on the shifts with missed or late doses

• The hospital record showing the harm

Chemical Restraints Are Elder Abuse
California requires informed consent before a nursing home gives a resident a psychotropic drug, and prohibits using drugs for discipline or staff convenience. A resident sedated into a chair for months is neglected under the Elder Abuse and Dependent Adult Civil Protection Act, and the facility’s own pharmacy reviews usually say so.

What Families Can Do

• Ask for the current medication list and compare it to what the physician ordered at the last visit

• Ask why any antipsychotic or sedative was started and whether consent was obtained

• Report sudden drowsiness, confusion, or a change in behavior the same day

• Request the pharmacy consultant’s monthly review in writing