Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by 10 medication errors out of 41 observed opportunities, resulting in an error rate of 24.39%. Two residents were directly affected by these errors. For one resident with a history of malignant neoplasm of the pancreas, hypertensive heart disease with heart failure, and difficulty walking, the facility did not administer carvedilol and pancrelipase within the prescribed time frame. The physician's orders specified that carvedilol should be given with breakfast and dinner, and pancrelipase with meals, both within a one-hour window of the scheduled time. However, the medications were not administered as ordered, and the resident reported not receiving them with breakfast as required. The nurse involved acknowledged the delay and confirmed it was outside the facility's policy for timely medication administration. Another resident, who had severe cognitive impairment, Parkinsonism, gastrostomy status, and a history of urinary tract infections, received eight crushed medications mixed together and administered at once via a gastrostomy tube. Facility policy required that each medication be crushed and administered separately, with a water flush between each to prevent drug interactions and tube clogging. The nurse administering the medications confirmed that she did not follow this protocol and instead gave all medications together in one dose. The DON also confirmed that this was not in accordance with facility policy and that medications should be given separately through the g-tube. Both incidents were confirmed through observation, interviews with staff, and review of medical records and facility policies. The facility's own policies defined these actions as medication errors, as they were not in accordance with physician orders, manufacturer specifications, or accepted professional standards. The errors were acknowledged by the staff involved and the DON, and the facility's documentation supported that the medications were not administered as required.