Medication Administration Errors and Noncompliance with Physician Orders
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 10.53% (4 errors out of 38 opportunities) during a medication pass observed by surveyors. In one instance, a registered nurse did not administer a resident's scheduled dose of Flonase nasal spray at 9 AM because it was unavailable, despite an active order for the medication. The omission was confirmed through review of the resident's electronic medication administration record (EMAR) and order summary report. Another resident received the incorrect dosage of Calcium Carbonate, being given 500 mg instead of the ordered 600 mg, and was not instructed to rinse her mouth after using a Breyna inhaler as required by the medication's instructions to prevent oral fungal infection. Additionally, a third resident was administered Amlodipine, an antihypertensive medication, without the nurse checking the resident's blood pressure prior to administration, contrary to the physician's order to hold the medication if systolic blood pressure was less than 90. The facility's policy requires that all medications be administered safely and according to physician orders.