Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a significant deficiency during the recertification survey. Specifically, two residents were affected by medication administration errors. Resident #27, who had diagnoses including cerebral infarction, type 2 diabetes, depression, and hyperlipidemia, was administered five medications over an hour late. Additionally, their sliding scale insulin dose was given after breakfast instead of before, as ordered, and the insulin pen was not primed, potentially affecting the insulin dosage received. The Licensed Practical Nurse (LPN) responsible for administering the medications admitted to being behind on their medication pass and did not follow the facility's protocol for reporting such delays. Resident #110, who had a gastrostomy tube and dysphagia, was administered four medications orally instead of via the gastrostomy tube as ordered. The LPN involved attempted to administer the medications by mouth to see if the resident could swallow them, despite not having a physician's order to change the route of administration. This action was taken without consulting the physician or waiting for the speech language pathologist to assess the resident's ability to swallow safely. The medications were also administered over an hour late, and the LPN did not seek approval from the physician for the delay. The facility's medication administration policy required that any errors be reported immediately to the attending physician and nursing administration. However, there was no documented evidence of such reporting or any facility policy on blood glucose monitoring and insulin administration. The Registered Nurse Educator and Licensed Practical Nurse Manager confirmed that the actions taken by the LPNs were not in accordance with the facility's protocols, highlighting a lack of adherence to established procedures and communication failures within the facility.
Plan Of Correction
Plan of Correction: Approved March 4, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents identified as #27 and #110 medication errors were identified and discussed with the Medical Director. LPN #24's agency was notified of errors. LPN has not returned to the facility. LPN #10 was provided education on correct medication administration. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? Medication administration observations will be completed on all diabetic residents receiving insulin. Medication documentation audit will be reviewed to identify late medication administration. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? Medication administration education and post test will be completed by all licensed nurses. Medication administration observation audit will be completed. 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 practice? Medication administration reports will be reviewed daily for two weeks. A random daily report weekly will be completed for three months. Further audits will be conducted dependent on results of observations and audits completed. The date for correction and the title of the person responsible for correction of each deficiency: Nurse Educator.