Medication Administration Errors Lead to Deficiency
Penalty
Summary
During a recertification survey, it was found that the facility did not maintain a medication error rate of five percent or less, as evidenced by a 7.7 percent error rate. Specifically, for one resident, there were two medication errors out of 26 opportunities. The errors involved the administration of midodrine and Vitamin B12. The midodrine was administered despite the resident's systolic blood pressure being above the parameter set by the physician's order, which indicated the medication should be held if the systolic blood pressure was greater than 90. Additionally, Vitamin B12 was administered without a prescribed dose being included in the physician's order. The resident involved had diagnoses including Parkinson's disease, atrial fibrillation, and type two diabetes, and was cognitively intact. The LPN responsible for administering the medication acknowledged the errors, stating that the midodrine should not have been given and that the Vitamin B12 should not have been administered without a verified dose. The Nurse Practitioner and Director of Nursing confirmed that the medication should have been held and that the order should have been verified before administration. The Director of Nursing also noted that the system should not allow incomplete orders to be saved, indicating a lapse in protocol adherence.
Plan Of Correction
Plan of Correction: Approved February 7, 2025 1. Resident #13. The resident was evaluated by the Medical Provider on 1/16/2025. The Nurse involved was provided counseling and re-education on 1/16/2025. 2. The facility will conduct a review of all current residents’ medication orders to ensure that all components of the order are present and review all current resident medication orders to ensure that all of the residents with parameters in the orders are being followed as written. The Medical Provider will be notified of any residents that were identified with significant findings. Any recommendations and changes in resident orders will be completed as written from the medical providers. Completion date: 2/28/2025 3. The facility will provide all licensed nurses with education on medication orders and reduction risks of medication errors. The facility’s medication administration policy has been reviewed with the Director of Nursing, Administrator, and Medical Director. Completion date: 2/28/2025 4. The facility Director of Nursing will conduct audits on all residents’ new orders to ensure all components, including the dose, are present in the order and all resident orders that have parameters to monitor for parameter compliance. Audits will be conducted weekly for three months and then monthly for three months.