Medication Error Rate Exceeds 5% Due to Improper Administration Practices
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.
Penalty
Resources
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An LPN contributed to a medication error rate of 10.71% after 3 errors were found in 28 observed medication opportunities. The LPN administered eye drops and ear drops to one resident without preventing the resident from wiping the medication away, and left another resident unsupervised during a nebulizer treatment without monitoring the response or cleaning the equipment afterward. Record review showed the resident receiving the nebulizer had no documentation supporting self-administration, and the facility's procedures required assessment and direct administration for these treatments.
Medication administration errors exceeded the allowed rate, with surveyors identifying multiple dose discrepancies and an enteral medication error during observed med passes. An MA gave a resident the wrong ferrous sulfate dose, another MA gave a resident several medications at incorrect strengths, and an LVN used another resident’s MiraLAX and did not complete the ordered G-tube water flushes before administration.
Medication error rate exceeded the allowed threshold. Surveyors calculated a 6.25% error rate based on 32 medication opportunities with 2 errors. In one case, an LPN gave a resident the wrong magnesium/calcium tablet strength compared with the active order for hypomagnesemia. In another, an LPN administered vitamin D3 400 units even though the resident’s order called for cholecalciferol 4000 units for vitamin D deficiency, and staff noted the pharmacy label still showed 400 units.
The facility’s medication error rate was 6.9%, with 2 errors found in 4 observed med passes. One nurse gave an insulin dose without priming the pen first, and another did not ensure a resident rinsed and spit after using a steroid-containing inhaler. The residents involved had DM and COPD, respectively, and both were moderately cognitively impaired.
Medication Error Rate Exceeded Standard During G-Tube Medication Administration. Surveyors found a 27.59% medication error rate during observation of medication administration. An LPN crushed multiple meds together, mixed them with water, and administered them through a resident’s g-tube without giving each medication separately. The resident had encephalopathy, dysphagia, malnutrition, severe cognitive impairment, and required tube feeding for nutrition. The resident’s orders did not include permission to combine the tablets, and the DON and ADON stated meds for tube administration should not be cocktailed.
Medication administration errors exceeded the allowed rate when seven errors were found in 31 opportunities. A nurse gave several scheduled meds to one resident more than 2 hours late, and another nurse crushed and gave three meds together through a G-tube to another resident instead of administering each med separately with flushes between doses, contrary to the DON’s expectations, the consultant pharmacist’s guidance, and facility policy.
Medication Error Rate Exceeded Threshold During Eye, Ear, and Nebulizer Administration
Penalty
Summary
A medication error rate of 10.71 percent was identified after 28 medication opportunities were observed and 3 errors were found, exceeding the 5 percent threshold. During one observation, an LPN administered prescribed eye drops to a resident with blepharitis and instilled 2 drops in each eye, but did not offer tissue or instruct the resident not to rub his eyes afterward; the resident immediately rubbed both eyes with his t-shirt and removed the drops. The same LPN then administered ear drops by placing the dropper tip inside the ear canal and instilling drops into both ears, after which the resident again wiped the drops away with his t-shirt. During another observation, the LPN prepared and started a nebulizer treatment for a resident who had an order for ipratropium-albuterol inhalation solution three times daily. The LPN handed the mask to the resident, instructed him to place it on himself, washed her hands, and left the room, leaving the resident unsupervised during the treatment and without monitoring the response or cleaning and disassembling the nebulizer equipment afterward. The LPN confirmed that the nebulizer treatment should not have been left unattended and that she did not perform an assessment before or after medication administration. Record review showed the resident had no documentation indicating self-administration of medications, and the facility's procedures required assessment, direct administration, and post-treatment evaluation for nebulizer use, as well as specific techniques for eye and ear drop administration.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. Surveyors identified a 26.67% medication error rate, based on 8 errors out of 31 opportunities, involving 3 residents and 3 staff members observed during medication administration. The errors included incorrect doses of ferrous sulfate for one resident and multiple medication dose discrepancies for another resident, as well as an error involving a third resident’s enteral medication administration. One resident with a history of cerebral infarction, muscle wasting, constipation, hypertension, and mixed hyperlipidemia had a physician order for ferrous sulfate 326 mg by mouth daily. During observation, MA I administered ferrous sulfate 325 mg instead. The resident had severely impaired cognition, with a BIMS score of 3 out of 15. During interview, MA I stated she did not notice the milligram difference and acknowledged she was responsible for ensuring the dosage was correct before administration. Another resident with osteomyelitis, muscle wasting, and anemia had orders for ferrous gluconate 324 mg, magnesium oxide 250 mg, vitamin C 1000 mg, folic acid 1000 mcg, and methocarbamol 1000 mg. During observation, MA F administered ferrous gluconate 325 mg, magnesium oxide 240 mg, vitamin C 500 mg, folic acid 400 mcg, and methocarbamol 500 mg. A third resident with cerebral infarction, dysphasia, and abdominal pain had an order for MiraLAX via G-tube and water flushes before and after medication administration. During observation, LVN N used another resident’s MiraLAX bottle, mixed it with water, and administered it without the ordered 50 cc water flush before medication administration.
Medication error rate exceeded the allowed threshold
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent; surveyors calculated a 6.25 percent error rate based on 32 medication opportunities with 2 medication errors. During observation of a medication pass for one resident, an LPN administered a Slow Magnesium/Calcium oral tablet 70-117 mg, while the active physician order called for Slow Magnesium/Calcium Delayed Release 64-106 mg, 1 tablet by mouth every morning and at bedtime for hypomagnesemia. During another medication pass observation, an LPN administered vitamin D3 400 units to a second resident. The resident’s active physician order, dated January 23, 2026, directed staff to administer cholecalciferol oral tablet 100 micrograms (4000 units), 1 tablet by mouth in the morning for vitamin D deficiency. An LPN later stated that the pharmacy supply continued to label the resident’s vitamin D3 supplement as 400 units, and confirmed that the physician order required 4000 units in the morning.
Medication Error Rate Exceeded Threshold; Insulin Pen Not Primed and Inhaler Rinse Not Completed
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent, with a measured medication error rate of 6.9 percent. During observation, record review, and staff interviews, surveyors identified 2 medication administration errors out of 4 observed administrations: one involving an insulin pen that was not primed before the ordered dose was given, and one involving an inhaled steroid medication where the resident was not instructed or assisted to rinse her mouth with water without swallowing after use. Resident #38 had diabetes mellitus and was moderately cognitively impaired. A physician ordered insulin degludec 58 units subcutaneously once daily. During observation, a nurse obtained the insulin pen, attached the needle, dialed the pen to 58 units, and administered the injection without first priming the pen. The nurse later stated she normally primes insulin pens but forgot to do so while being observed. Staff Development, the DON, the NP, and the Administrator all confirmed that the pen should have been primed according to the manufacturer’s instructions before the dose was administered. Resident #50 had COPD and was moderately cognitively impaired. A physician ordered fluticasone furoate, umeclidinium, and vilanterol aerosol powder, 1 puff daily, with instructions to rinse the mouth after use. During observation, the resident used the inhaler, but the nurse did not provide water or instruct the resident to rinse and spit afterward; instead, the resident was given laxative solution mixed with water and drank it. The nurse acknowledged she did not offer or encourage the rinse and stated the resident had refused in the past, but those refusals had not been documented or reported. The DON, NP, and Administrator confirmed that the mouth rinse should have been offered and that prior refusals should have been documented and communicated.
Medication Error Rate Exceeded Standard During G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure the medication error rate was not 5% or greater. Surveyors found a medication error rate of 27.59%, based on 8 errors out of 29 opportunities, involving 1 of 5 residents and 1 of 3 staff observed during medication administration. The deficiency centered on Resident #6, a male with diagnoses including encephalopathy, dysphagia, and malnutrition, whose cognitive skills were severely impaired and who required a feeding tube for nutrition. His care plan reflected the need for tube feeding for all nutrition and checking tube placement per facility protocol. During observation, LVN F prepared multiple medications together in one medication cup, including Vitamin D3, acetaminophen, ascorbic acid, zinc sulfate, thiamine, Eliquis, tizanidine, and atorvastatin, then crushed the tablets together and mixed them with water. LVN F entered the resident’s room and administered the medications through the g-tube without giving the tablets separately. The nurse also administered multivitamin and Prostat through the tube during the same medication pass. The resident’s order summary reflected no physician order to combine medication tablets or cocktail medications. In interview, LVN F stated he typically crushed medications together if they were not enteric coated and acknowledged that giving the medications together could put the resident at risk of medication interaction and cause an adverse reaction. The ADON and DON both stated that medications for g-tube administration should be crushed and administered separately and not cocktailed.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5% when seven medication errors were identified out of 31 opportunities, resulting in a medication error rate of 22.58% for a census of 91. During a concurrent medication administration observation and interview, a nurse prepared and administered four medications for one resident after the scheduled 8:00 a.m. time, with the medications given between 10:04 a.m. and 10:14 a.m. The resident’s orders included hydralazine hydrochloride 50 mg via G-tube every 8 hours, metoprolol tartrate 25 mg via G-tube twice daily, levetiracetam 100 mg/mL 10 mL via G-tube twice daily, and Humulin R 8 units subcutaneously three times daily. The DON stated medications should be given within one hour before and one hour after the scheduled time, and the facility policy stated medications are to be administered within one hour of the prescribed time. During another medication administration observation, a nurse crushed and combined three medications together and administered them via G-tube to another resident: carvedilol 12.5 mg, empagliflozin 10 mg, and sacubitril-valsartan 49-51 mg. The consultant pharmacist stated these medications should not be crushed together because there was no literature supporting that crushing and administering them together would avoid physical or chemical incompatibilities, and nurses were expected to crush medications individually and administer each medication with flushes in between. The facility’s policy for administering medications through an enteral tube stated that each medication should be administered separately and flushed between medications.
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