Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate during observations of medication administration. Two residents were involved in the errors. The first resident, diagnosed with diabetes and renal insufficiency, was supposed to receive 8 units of Novolog insulin. However, the LPN administering the insulin did not follow the manufacturer's instructions, which required the needle to remain in the skin for at least 6 seconds to ensure the full dose was delivered. Instead, the needle was removed after only one second, potentially compromising the effectiveness of the insulin dose. The second resident, diagnosed with diabetes and macular degeneration, was to receive 6 units of Lispro insulin. The LPN did not properly prime the insulin pen or ensure the needle was in place for the required time as per the manufacturer's instructions. The pen was held in place for only 3-4 seconds instead of the recommended 5 seconds, and the LPN did not verify that the dose counter showed zero after administration. These actions led to a failure in ensuring the resident received the correct insulin dosage, contributing to the facility's medication error rate exceeding the acceptable threshold.