Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
Surveyors identified that the facility failed to ensure medications were administered accurately and as ordered for two of four residents observed during medication pass, resulting in a medication error rate of 11.11%. The facility's policies require adherence to the 10 Rights of Medication Administration and specific procedures for nasal spray, inhaler, and eyedrop administration. However, staff did not follow these protocols during observed medication passes. For one resident, a registered nurse withheld a prescribed blood pressure medication (Toprol XL) due to a low blood pressure reading, despite the absence of physician-ordered parameters for withholding the medication. The nurse did not notify the physician and administered the medication three hours late after a subsequent blood pressure reading. The same resident was not given proper instruction for self-administering a nasal spray, resulting in the resident using an incorrect number of sprays, and did not receive ordered ophthalmic eye drops as scheduled. For another resident, a licensed practical nurse failed to instruct the resident to close their eyes or hold the inner canthus after administering prescribed eyedrops, did not provide guidance on proper nasal spray technique, and did not assist or instruct the resident to rinse their mouth after using an inhaled corticosteroid, contrary to both facility policy and FDA labeling. Interviews with staff and the Director of Nursing confirmed a lack of clarity regarding medication administration parameters and inconsistent adherence to established protocols.