Medication Administration Errors and Patch Mismanagement
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 12.5% error rate observed during a medication administration review. This was based on 32 medication administration opportunities, where four errors were identified. One significant error involved a resident who was supposed to receive aspart insulin before breakfast. However, the insulin was administered after the resident had already eaten, which was not in accordance with the physician's orders. The licensed nurse, Employee E8, confirmed the error during the observation. Additionally, there was a failure to adhere to the prescribed schedule for lidocaine patch application and removal. The resident had orders for lidocaine patches to be applied to both knees at 9:00 a.m. and removed at 9:00 p.m. However, the patches were not removed until the following day, and new patches were applied immediately after the old ones were removed. This oversight was acknowledged by Employee E8, who confirmed that the patches should have been removed the previous evening, as per the physician's orders.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R132 physician was made aware that the resident received insulin after breakfast and was made aware of the lidocaine patches that were not removed per order. The DON/designee educated licensed staff including agency licensed staff on the medication administration policy which includes timely administration of insulin and topical lidocaine patch removal per orders. The DON/designee will conduct random medication pass observations of 5 licensed staff focusing on residents with orders for insulin and topical lidocaine patches. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.