Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a ten percent error rate based on 30 medication opportunities with three errors. One incident involved a resident whose medications were improperly crushed and administered by an LPN. The resident was prescribed Isosorbide Mononitrate ER and Pantoprazole Sodium DR, both of which should not be crushed. The LPN crushed these medications and administered an incorrect dosage of Pantoprazole, giving 40 mg instead of the prescribed 20 mg. This error was confirmed during an interview with the LPN, and the facility's documentation indicated that these medications were on a list of drugs that should not be crushed. Another incident involved the administration of insulin to a different resident using a Humalog Kwikpen. The LPN failed to prime the pen before administering the insulin, which is a necessary step to ensure the correct dosage is delivered. This oversight was confirmed in an interview with the LPN. The facility's failure to adhere to proper medication administration protocols was discussed with the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing.
Plan Of Correction
The facility is unable to retroactively correct the medication errors for residents 40 and 66. A house audit of current residents' medication was completed to ensure proper orders for administration were in place for crushed medications and insulin. Licensed nurses were educated on appropriate crushing of medications and proper use of insulin syringes. The DON or designee will complete med pass observations of 3 licensed staff a week x 8 weeks to ensure appropriate administration. If variances are identified, the nurse will receive re-education. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.