Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered by a physician for two residents, leading to deficiencies in pharmaceutical services. For Resident #6, a discrepancy was observed in the administration of Lactulose. The medication was administered at 15 ml, while the physician's order specified 10 ml daily. This error was identified during a medication administration observation and confirmed through interviews with the RN and the Director of Nursing (DON). The DON acknowledged the error, stating that the order should have been 10 ml daily, and an incident report was completed. Resident #6 was not harmed by this discrepancy. For Resident #1, there was a failure to administer Midodrine Hydrochloric Acid as ordered. The physician's orders required the medication to be given every eight hours via PEG tube for hypotension, with specific instructions to monitor vital signs. However, nursing notes revealed that the medication was not administered as scheduled, and the resident experienced high blood pressure during the shift. The DON explained that the facility does not have standard parameters for medications affecting blood pressure unless specified by the physician. The staff pharmacist confirmed that routine orders for Midodrine typically do not include parameters, except for contraindications like persistent supine hypertension. The facility's policy on medication administration emphasizes that medications should be administered as prescribed and in accordance with good nursing practices. However, the discrepancies in medication administration for both residents indicate a failure to adhere to these guidelines. The facility's medication distribution system is designed to ensure safe administration, but the errors in following physician orders for Resident #1 and Resident #6 highlight lapses in this system.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 is no longer at the facility. Resident #6's order was corrected. The physician was called and was advised of the incorrect dosage being administered, and no new orders were given. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken? All residents with orders were reviewed; any deficiencies found were corrected immediately. An audit was conducted which reviewed a sample of new orders for accurate transcription, and if any deficiencies were found, they were addressed immediately. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; and? Standard parameters will be established through the therapeutic and pharmacy committee. All nursing staff will be educated on utilizing the standard parameters for orders, unless the physician ordered otherwise. An audit will be conducted to review orders daily by the nurse managers and pharmacist for 7 days, then weekly for 30 days, and then monthly for 3 months. If any deficiency is found, it will be corrected immediately. Nursing staff will be educated on accurately administering medications per physician's orders by following the Five Rights. A sample of new orders will be randomly audited on all units by the unit manager or designee daily for 7 days, then weekly for 30 days, and then monthly for 3 months. Additionally, the pharmacy representative will be conducting random medication administration pass observations weekly for 3 months; if any deficiencies are observed, education will be provided to the nurse immediately. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? This corrective action plan will be monitored through a dedicated PIP, and nursing home leadership will report findings to the monthly Quality and Risk Management committee. The committee will also evaluate the need for extended audits and further education, if necessary, after 90 days.