Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by the administration errors involving Resident R51. On February 5, 2025, a Licensed Nurse, identified as Employee E5, administered Memantine 5 mg in tablet form after crushing it, contrary to the physician's order which specified Memantine HCL, ER 7 mg Capsule to be given whole. The nurse confirmed the medication as Memantine 5 mg tab, which was incorrect according to the resident's prescribed treatment plan. The literature review indicated that enteric-coated medications like Memantine ER should not be crushed, highlighting a significant deviation from proper medication administration protocols. Additionally, the same nurse administered Ferrous Sulfate 325 mg RED Type in a crushed form, despite the physician's order to administer it as a whole tablet. The literature review supported that Ferrous Sulfate tablets should not be crushed, further contributing to the medication error rate. These errors were confirmed by the Director of Nursing during an interview, resulting in a calculated medication error rate of 7.14%, which exceeds the regulatory threshold of five percent.
Plan Of Correction
1. R51's medication orders were reviewed and clarified by the physician including the addition of an order that licensed staff may crush crushable medications on 2/10/2025. R51 experienced no ill effects from this event. E5 was re-educated on the "Medication Administration Policy" and the "Do Not Crush" listing. 2. The Director of Nursing or designee will conduct an audit on current residents' medication orders to ensure that residents have an order, if applicable, that licensed staff may crush crushable medications by 2/28/25. The Director of Nursing or designee will audit the medication pass of current residents to ensure compliance with physicians' medication orders and that only applicable medications are being crushed by 2/28/25. 3. The Director of Nursing or designee will provide re-education to current licensed staff on the "Medication Administration Policy" and the "Do Not Crush" listing including the requirement to adhere to the orders of the prescriber by 3/10/25. 4. The Director of Nursing or designee will complete a random audit on the medication pass of 5 residents to ensure compliance with physicians' medication orders and that only applicable medications are being crushed weekly for 4 weeks and then monthly for 2 months. The results of these audits will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.