Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to ensure that all medications were administered without a medication error rate of 5% or more. During a morning medication administration observation, a surveyor observed three nurses administering medications to six residents. Out of 27 opportunities, two errors were observed, resulting in a medication administration error rate of 7.4%. The errors were identified for one resident, who was administered medications by one of the three nurses observed. The deficiency was evidenced when a Registered Nurse (RN#1) administered the wrong dose of a medication to a resident. The RN was observed applying a medication patch to two different sites on the resident, but the strength of the medication applied was not as ordered. The RN acknowledged the error after the surveyor pointed it out, and it was confirmed that the physician was contacted regarding the error. The facility's medication administration policy did not reflect procedures for ensuring the administration of the correct dosage. The surveyor's review of the resident's medical record revealed active physician orders for the medication to be applied to two different sites. The facility's staff, including the person responsible for nursing staff education, acknowledged the error and stated that the nurse should have contacted the physician if the correct medication was not available. The facility had provided inservice training on medication administration, but the error still occurred, indicating a lapse in following the correct medication pass procedures.
Plan Of Correction
Element 1 Upon identifying the error with the applied to Resident #122, immediate corrective actions were taken. The resident's condition was assessed to determine if any adverse effects occurred due to the incorrect patch. The physician was promptly notified and consulted to evaluate whether any further medical intervention was necessary. The physician initially issued a one-time order for the [R], which was applied. Following this, the order was permanently revised to the NJ Exec Order 26.4b1. The nurse who administered the incorrect patch was counseled and retrained on the proper procedures for administering lidocaine patches, including verifying the correct strength based on the physician's order. A medication error form was completed immediately, and the nurse was successfully re-med passed. Element 2 All residents receiving topical analgesic treatments, such as lidocaine patches, may be at risk. Element 3 Additionally, all nursing staff were educated on key points, including: not borrowing medications, the distinction between OTC 4% lidocaine patches and prescription 5% patches, and the rights of medication administration (right patient, right drug, right dose, right dosage form, right route, and right time) by the Assistant Director of Nursing. A follow-up monitoring plan was also implemented to ensure the residents' comfort and safety with the newly revised order for the 4% lidocaine patch. A comprehensive review of all residents receiving topical analgesic treatments, including lidocaine patches, was conducted. An audit was completed to ensure that all patches in stock were properly dosed and matched the physician's orders. Element 4 Patch spot check audits will be conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance that all medications are administered according to physician orders. All residents receiving patches will be verified to ensure the correct dosage was applied and is available. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing, and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for nine months to the Quality Assurance Performance Improvement team for review and action as necessary.