Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 12.82% error rate for a resident. During a medication administration observation, an LPN prepared and administered nine crushed medications via a PEG tube for a resident. The LPN initially flushed the tube with 30 to 40 mls of water, followed by four medications with an additional 20-30 mls of water. The resident reported feeling full and nauseous, prompting the LPN to pause. The LPN then combined the remaining five medications into 30 mls of water and flushed with another 20-30 mls of water, leaving residual medication in the syringe. The LPN admitted to combining medications for some residents, although this was not ordered for the resident in question. The facility's policy requires each medication to be administered separately, diluted with at least 30 ml of water.
Plan Of Correction
Element 1: It is the practice of the facility to be free of medication error rates of 5%. Element 2: Residents that receive medications via PEG tube have the potential to be affected by this cited practice. R73 stated she was fine and that she always feels full. R73 was offered to take her medications by mouth and stated she prefers her medication via PEG. LPN E was educated on medication administration via PEG tube. Element 3: The Interdisciplinary Team reviewed the policy and procedure on medication error and deemed it to be appropriate. Nursing was educated on medication errors and medication administration via PEG. Element 4: Nurse Educator/Designee will audit random nurses weekly x4 for proper medication administration via PEG, then monthly x3. Results of audits will be taken through QA for further review and recommendations. Element 5: The Administrator will be responsible for sustaining compliance.