Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility was cited for a medication administration error resulting in a medication error rate of 7.14%, exceeding the acceptable threshold of less than 5%. During the recertification survey, it was observed that an LPN administered the wrong medication to a resident. Specifically, the LPN gave [MEDICATION NAME] Silver Ultra Men's 300 mcg-60 mcg-600 mcg-300 mcg instead of the prescribed [MEDICATION NAME] Silver 0.4 mg-300 mcg 250 mcg. The error occurred because the LPN did not find the correct medication in the medication cart and mistakenly selected a medication intended for another resident. The LPN admitted to signing off on medications before administering them, intending to give all medications at the same time for convenience. This practice was against the facility's policy, which requires medications to be charted immediately after administration. The LPN also acknowledged not recognizing the correct medication due to unfamiliarity with its listing under another name. Interviews with the unit supervisor and the Medical Director confirmed that the medication was available but not correctly identified by the LPN. The facility's policy prohibits borrowing medications from one resident for another, and the error highlighted a lapse in adherence to the five rights of medication administration.
Plan Of Correction
Plan of Correction: Approved April 25, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F759** I. Immediate Corrective Action: 1) On 3/26/25 Resident # 320 was assessed by the MD/NP and no adverse effects of receiving late administration of [MEDICATION NAME] and the administration of a different type of [MEDICATION NAME] were noted. 2) On 3/26/25 a medication error report was developed by the DON for this incident and shared with Pharmacy Consultant and Medical Director. 3) On 4/1/25 the DON issued a disciplinary action for LPN# 3 responsible for the medication error. 4) On 4/1/25 a Medication competency was conducted by the RNS for LPN #3. II. Identification of Others: 1) The facility respectfully states that all residents were potentially affected. 2) The DON conducted a meeting with the Medical Director and Pharmacy consultant to review any medication errors in the past 3 months to assess Facility medication error rate. No medication errors were reported. III. Systemic Changes: The DON, Medical Director and Administrator in conjunction with the Pharmacy Consultant reviewed the Facility policies/procedures for medication administration and found same to be compliant. The P/P will be inserviced to all Licensed Medication nurses by the Inservice Coordinator. The Lesson plan will focus on: - Standard for safe medication practices: The Rights of Medication Administration that include: - Right patient - Right drug - Right dose - Right route - Right time - Right reason - Right Monitoring (including vital signs and observation for side effects) - Right documentation - Right patient education - Right evaluation - Right to refuse. - Types of Medication Errors - Medication Documentation and communication. IV. Quality Assurance 1) The DON will develop an audit tool to monitor compliance with ensuring compliance with standards of practice for Medication Administration. 2) The audit will be done by the DON/Designee on 4 randomly selected medication nurses on random shifts weekly x 4 weeks, followed by 4 randomly selected medication nurses monthly x 6 months. 3) All Nurses will continue to have a Medication Competency upon hire and annually completed by the Inservice Coordinator /Designee. 4) Results from the audit will be brought to the Quarterly QA Meeting to monitor compliance and track sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025 - Director of Nursing