Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with seven medication errors identified out of 28 opportunities, resulting in a 25% error rate. For two residents, a licensed vocational nurse (LVN) administered scheduled 9 a.m. medications earlier than the prescribed time without proper documentation or provider authorization. The LVN stated that the residents preferred to receive their medications earlier, and although the nurse practitioner or physician was reportedly notified, there was no documented order to change the scheduled administration time. Facility policy and interviews with the Director of Pharmacy and Director of Long-Term Care confirmed that medications should be administered within one hour before or after the scheduled time, and any deviations require provider approval and documentation. In another instance, the same LVN failed to follow facility policy for administering medications via gastrostomy tube (g-tube) for a resident with epilepsy, muscle spasm, neuralgia, and neuritis. The LVN did not flush the g-tube with water between administering different medications, contrary to the facility's policy, which requires flushing with 15-30 ml of water between each medication to prevent mixing and ensure tube patency. The LVN stated she followed the physician's order to flush before and after medication administration but did not flush between medications due to the absence of a specific order. Interviews with facility leadership confirmed that the standard of practice and facility policy require flushing between medications, and the LVN acknowledged not following this procedure. Additionally, the LVN did not check the g-tube for placement and patency at every scheduled medication administration, as required by facility policy. Instead, she checked for patency only once per shift, based on instructions she believed were provided by her supervisor. However, facility leadership clarified that the policy is to check placement, patency, and residual before every medication administration. The failure to adhere to these procedures was confirmed through interviews, record reviews, and direct observation, and was not in accordance with the facility's written policies and procedures for safe medication administration.