Medication Administration Errors and Policy Noncompliance
Penalty
Summary
Surveyors identified a medication error rate of 18.75% during medication administration observations, with six errors out of 32 opportunities involving three residents. One incident involved a nurse administering Brimonidine Tartrate eye drops to a resident with glaucoma without following proper technique. The nurse did not instruct the resident to look up, failed to pull down the lower eyelid to create a pocket, and instilled the drop directly into the inner corner of the eye. Additionally, the nurse did not apply gentle pressure to the tear duct after administration, and another staff member immediately wiped the eye, contrary to recommended procedures and the facility's policy. Another deficiency was observed during the administration of medications via gastrostomy tube (G-tube) for a resident. The nurse crushed multiple tablets together and mixed them with a powdered medication in a single cup, then administered the mixture through the G-tube without flushing between each medication. The nurse acknowledged that medications should have been crushed and administered separately with water flushes in between, as per physician orders and facility policy, to prevent drug interactions and tube obstruction. A third incident involved a resident not receiving a scheduled dose of tamsulosin due to the medication being unavailable in the facility. The nurse was unable to locate the medication and reported that it would be delivered later by the pharmacy. The medication administration record reflected that the dose was not given, and the Director of Nursing confirmed that the medication should have been available and administered as ordered. These failures demonstrate noncompliance with physician orders and facility procedures for medication administration.