Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate based on 25 medication opportunities with two errors. One error involved the administration of insulin to a resident using a Fiasp FlexTouch pen. The LPN did not follow the manufacturer's instructions for priming the pen, which required two units of insulin to be used for priming. Instead, the LPN primed the pen with only one unit before administering the prescribed two units to the resident, who had a blood glucose level of 199 mg/dL. Another error occurred during the administration of Polyethylene Glycol to a different resident. The LPN used a plastic medication cup to measure the dose instead of the cap provided with the medication container, which is designed to measure the correct 17 grams dose. This resulted in the resident receiving an incorrect amount of the medication. The LPN confirmed the errors during an interview, acknowledging the lack of access to the manufacturer's instructions for the insulin pen and the incorrect measurement method for the Polyethylene Glycol.
Plan Of Correction
1. Facility can not retroactively correct deficient practice. Resident 2: - The physician was notified of the insulin administration error, and no adverse effects were noted. - The insulin pen administration policy was reviewed, and staff were re-educated on proper priming procedures. Resident 14: - The physician was notified of the Polyethylene Glycol administration error, and no adverse effects were noted. 2. Facility will review and update their Policy and Procedures specifically: - The facility's "Administering Medications" and "Insulin Administration" policies were updated to: - Include detailed priming instructions for all insulin pens based on manufacturer guidelines. - Emphasize measuring medications using manufacturer-provided tools. - The medication administration policy was reviewed, and staff were re-educated on measuring medications according to manufacturer instructions. 3. All licensed nurses will be educated on updated policies and ensuring to follow manufacturer guidelines and will complete competency assessments on: - Insulin administration using prefilled pens and priming. - Proper measurement of powdered medications based on manufacturer guidelines. 4. The Director of Nursing (DON) or designee will conduct random medication pass audits on five nurses per week for four weeks to ensure: - Proper priming of insulin pens. - Correct medication measurement techniques on powdered medications. Audits will be conducted monthly for two months and Medication pass audit results will be reviewed in monthly QAPI meetings to ensure continued compliance and determining ongoing auditing.