Medication Administration Errors and Non-Compliance with Physician Orders
Penalty
Summary
During a recertification survey conducted from February 11 to February 19, 2025, it was found that the facility failed to maintain a medication error rate of five percent or less, resulting in a rate of 12.5 percent. This was due to the improper administration of medications to two residents. Specifically, enteric-coated, extended-release, and sustained-action medications labeled 'Do Not Crush' were crushed and administered. Additionally, cardiovascular medications were given without checking the required vital signs, such as blood pressure and heart rate, as per physician orders. One resident, diagnosed with atrial fibrillation, hypertension, and chronic kidney disease, was prescribed diltiazem and metoprolol, both with specific hold parameters for heart rate and blood pressure. However, these medications were crushed and administered without obtaining the necessary vital signs. The LPN involved acknowledged missing the hold parameters and admitted to the error of crushing the medications. The electronic medical record showed no documentation of vital signs being checked before medication administration. Another resident, with diagnoses including gastro-esophageal reflux disease and Alzheimer's disease, was prescribed pantoprazole, an enteric-coated medication. This medication was also crushed and administered despite the 'Do Not Crush' label. Interviews with facility staff, including a Physician Assistant and the Director of Nursing, confirmed that medications labeled 'Do Not Crush' should not be crushed, and vital signs should be checked and documented before administering medications with hold parameters.
Plan Of Correction
Plan of Correction: Approved March 17, 2025 1. The Licensed practical nurse immediately acknowledged the error and gave the residents uncrushed prescribed medication. 2. Assessments were done for all other residents on the Nurse's assignment, and no other residents were affected. 3. Nurse educator will provide all licensed practical nurses mandatory medication administration, documentation, and error prevention training starting 3/10/2025. 4. Two to three weekly medication audits will be conducted for all nurses. These results will be presented to the QA committee monthly for three months. The committee will determine the frequency of the audits thereafter. Responsible Party: Director of Nursing