Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, resulting in a rate of 6.25 percent. During medication administration observations, two errors were identified out of 36 opportunities. One error involved a Licensed Practical Nurse (LPN) administering Hydralazine to a resident without first checking the resident's blood pressure and pulse, as required by the physician's orders. The LPN confirmed that she did not obtain these vital signs prior to administration, and there was no documentation in the resident's clinical record to indicate that the necessary checks were performed. Another error involved the administration of Lispro Insulin to a resident. The LPN administered six units of Lispro Insulin based on the resident's blood glucose reading, but the insulin was given approximately 41 minutes before the resident received her meal, contrary to the manufacturer's instructions that it should be administered 15 minutes before or immediately after a meal. The Director of Nursing confirmed that the insulin should have been administered according to the manufacturer's guidelines.
Plan Of Correction
1. The medication administration for R54 cannot be corrected. The parameters for antihypertensive medication for R54 was immediately corrected. 2. The Director of Nursing or designee will audit current resident's insulin medication administration record (MAR) for accuracy of timing of insulin administration and antihypertensive medications for correct administration parameters if indicated in the physician order. 3. The Director of Nursing or designee will re-educate all licensed professional nurses on the facility policy and procedure for timing of administration of insulin and administration parameters for antihypertensive medications. 4. The Director of Nursing or designee will audit 25% per unit of all timing of insulin administration and parameters for antihypertensive medications. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.