Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 13.79% during the observation of 29 medication administration opportunities involving five residents and four nurses. One significant error involved RN Staff R, who administered medications to a resident without adhering to the physician's orders. Specifically, RN Staff R applied Lidocaine patches with a 5% concentration instead of the prescribed 4%, administered Loratadine 10 mg without a physician's order instead of the prescribed Cetirizine 10 mg, and failed to administer the correct dosage of Venlafaxine, omitting the additional 37.5 mg required to meet the total prescribed dose of 112.5 mg. Another error was observed with RN Staff K, who administered Torsemide 10 mg to a resident instead of the prescribed 5 mg for the treatment of Congestive Heart Failure and edema. Both nurses acknowledged their errors during interviews, with RN Staff R expressing confusion between Loratadine and Cetirizine and not realizing the discrepancy in Lidocaine patch strength. These errors highlight a lack of adherence to physician orders and medication administration protocols, contributing to the facility's elevated medication error rate.
Plan Of Correction
A. License Nurses was educated on F759 documentation and medication administration. This education will be provided annually and upon new hire orientation. B. Nursing Managers will audit medication administration for any documentation of such as but not limited to not available, holes/blanks in the MAR, and ensure that appropriate follow-up was completed. C. Medication competency was completed for current license nurses and any new license nurse hired. 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. The Director of Nursing/Designee will do random audits of license nurses during medication administration to ensure proper procedure/techniques is being utilized weekly for four weeks, then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.