Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure that all medications were administered without error, resulting in a medication administration error rate of 7.6%, which exceeds the acceptable threshold of 5%. During a medication pass observation, two errors were identified involving two residents. The first error occurred when an LPN prepared medication for a resident with a physician's order for Sennosides - Docusate sodium 8.6 mg - 50 mg. Instead, the LPN poured Sennoside 8.6 mg from a house stock bottle, which was incorrect according to the physician's order. This error was acknowledged by the LPN upon review with the surveyor. The second error involved another LPN who prepared medication for a resident with a physician's order for Amlodipine 10 mg, which required holding the medication if the systolic blood pressure was less than 110. The LPN recorded the resident's blood pressure from a notebook into the electronic Medication Administration Record (eMAR) but admitted to taking the blood pressure earlier in the morning rather than immediately before administering the medication, as required by the physician's order. These deficiencies were discussed with the Director of Nursing and other facility leaders during the survey.
Plan Of Correction
Based on observation, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication pass on 12/4/24, the surveyor observed five (5) nurses administer medications to six (6) residents. There were 26 opportunities, and two (2) errors observed which calculated to a medication administration error rate of 7.6%. The deficient practice was identified for 2 of 5 nurses for 2 of 6 residents, (Resident #97 and #20). 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: "LPN #1 was educated by the Director of Nursing about verification of correct medication during medication administration and process to follow if a medication is not available. A medication administration observation was completed on LPN #1 by the Director of Nursing. Resident #97 did not receive the wrong medication and was [R] by the deficient practice. LPN #2 was educated by the Director of Nursing about proper medication administration procedure when administering NJ Ex Order 26.4(b)(1) medication with a NJ Ex Order 26.4(b)(1). LPN #2 was educated to complete blood pressure right before administering medication. The LPN #2 completed NJ Exec Order 26.4b1 right after and administered medication as per protocol. Resident #20 was not affected by the deficient practice. A medication administration observation was completed on LPN #2 by the Director of Nursing. 2. Identification of residents who have the potential to be affected by the same deficient practice: "All residents have the potential to be affected by the deficient practice. 3. Systemic changes to ensure that the deficient practice does not recur: "Education completed, and the medication administration policy and procedure revised and updated on 12/20/24, with all nurses. The pharmacy consultant will continue with medication administration observations and education monthly to ensure competency of all nurses. 4. Monitoring of corrective actions: "The Director of Nursing or designee will complete medication observation on 3 nurses monthly for 6 months to ensure competency of nurses with an emphasis on medication verification and blood pressure completion right before administering hypertensive medications with BP parameter. "Results of the audit will be presented and reviewed during the quarterly Quality Assurance Performance Improvement (QAPI) meeting for 6 months, and additional corrective action will be implemented if deficiencies are identified.