Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 13.33% based on four medication errors out of thirty opportunities. Surveyors observed multiple instances where nursing staff did not follow physician orders or facility policy during medication administration. For example, a registered nurse crushed potassium chloride extended-release capsules for two residents, despite clear physician instructions and labeling that the medication should not be crushed. In both cases, there were no physician orders or care plan indications permitting the medications to be crushed. Another resident was observed chewing a potassium chloride capsule, which was not administered with water as required by FDA guidelines and facility policy. The nurse did not document the resident's difficulty swallowing the medication, nor was the physician notified that the resident did not receive the full prescribed dose or that a change to a liquid form might be needed. Additionally, a nurse failed to shake a bottle of senna oral syrup before administration and combined the unshaken liquid with other crushed medications in coffee, again without a physician's order or care plan direction to do so. The Director of Nursing confirmed that medications labeled as "do not crush" should not be altered without a physician's order, and that proper procedures for medication administration, documentation, and disposal were not followed in these cases. Facility policy also requires hand hygiene between residents, destruction of unused medications, and notification of the physician if a resident does not take medications as prescribed, none of which were consistently observed during the survey.
Plan Of Correction
The facility will develop a plan to maintain a medication error rate of 5% or less. For Resident #95, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #8, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #70, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #23, a review of bowel movements was completed by DON to assure that the resident did not have any unusual increased or decreased frequency of bowel movements. The resident was also monitored through daily nursing notes and CNA task documentation. ADON identified all residents who receive potassium and all who receive crushed, opened, or modified medications that had the potential to be affected. Immediate 1:1 education was given to nurses in the facility on Do Not Crush medications. DON and ADON reviewed the Medication Administration Policy and updated the Oral Crushed Medication section to reflect that a physician order is needed to crush any medication and to administer multiple crushed medications together. DON and ADON completed a Root Cause Analysis (RCA). They created a Relias module and posttest reinforcing the following: - If a pill is dropped onto the cart or floor, place it in the Drug Buster and retrieve a new pill to administer. - Shake well to mix suspensions. - Crushed medications require a Physician order to crush. - Potassium orders require a DO NOT CRUSH order but may be opened and sprinkled. - If a resident refuses medications, document in EHR and notify the Charge Nurse. - If medication has been prepared and then refused, destroy it in the Drug Buster. - Perform hand hygiene prior to administering medication. - Perform hand hygiene after medication administration. - If a resident is displaying difficulty with any medication (e.g., taste, form, size), notify the physician. - For employees who are casual/student status, on vacation, or on leave of absence (LOA), training will be completed before or during their next scheduled shift. DON provided a full list of residents who receive crushed medications to DNP for review and to write an order for long-acting medications indicating: 1) Do Not Crush OR 2) Do Not Crush, but may open and sprinkle and combine OR 3) May crush and Do NOT combine OR 4) May crush and combine Once orders are processed, MDS will update the Care Plan to reflect this. DON created a new form: Refusal of Medication/Medication Change Request Form, for charge nurses (notified by neighborhood nurses) to fill out for residents who may require a change in medication for any reason. Completed forms will be given to DNP for any necessary action. DON verified that audits are performed monthly by the pharmacy consultant for any residents who should have an order stating Do Not Crush. The Omniviews DO NOT CRUSH medication list was added to all units' medication information binders, placed at the north side nurses' station, and given to Administrative Medical Assistants. To ensure the policy review and changes are followed, DON/ADON or designee will randomly audit a medication pass with a focus on: - Medications are not being altered or combined without an order - No prepared medication stored in the medication cart - Performing hand hygiene - Medication disposed of appropriately if contaminated or refused - Shaking of liquid medications - Notification to the charge nurse for medication refusal Audits will occur on two nurses weekly on each shift for one month, then one nurse on each shift weekly for two months, and then one nurse monthly on an ongoing basis to ensure compliance with facility guidelines. The pharmacy consultant will audit residents' orders monthly and ensure Do Not Crush orders are present for medications that should not be crushed, sending recommendations if an order is missing. The MDS coordinator or designee will conduct quarterly audits to verify that any resident on crushed, opened, modified, or combined medications has a corresponding intervention in their care plan. DON will present a compliance report based on the audit findings at monthly QAPI meetings for review by the team for three months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. Ongoing monitoring thereafter will be continued by DON to ensure compliance in accordance with the plan of correction. DON will be responsible for attaining and sustaining overall compliance with this plan of correction.