Medication Error Rate Exceeds 5% Due to Insulin and Omeprazole Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 2 errors out of 30 observed medication administration opportunities, resulting in a 6.67% error rate. One incident involved a resident with diabetes who was prescribed Novolog insulin via a sliding scale. The nurse administered the insulin dose based on an outdated sliding scale taped inside the resident's supply bin, rather than the current order in the electronic medication administration record (EMAR). Additionally, the nurse did not prime the insulin pen prior to administration, contrary to manufacturer instructions. Interviews revealed inconsistent practices among staff regarding verification of insulin orders and updating of sliding scale references in the medication bins, with some staff relying on printed orders and others on the EMAR. The Director of Nursing acknowledged that the process for updating sliding scale orders in the bins was not consistently followed, and there was no facility policy for insulin flexpen administration. Another error involved a resident with GERD and dysphagia who was prescribed omeprazole delayed release (DR) capsules to be administered in the morning. The certified medication aide crushed the omeprazole DR capsule along with other medications and administered the mixture with applesauce while the resident was eating breakfast. According to the pharmacist, omeprazole DR should not be crushed, as this alters its delayed-release properties, and it should be given 30 to 60 minutes before a meal. Facility policy also states that long-acting or enteric-coated medications should not be crushed and that alternatives should be sought if necessary, with pharmacist consultation required. Both incidents demonstrate failures to follow physician orders, manufacturer instructions, and facility policy regarding medication administration. The errors were directly observed during surveyor review, and staff interviews confirmed lapses in verifying current orders and proper medication administration techniques. The facility's lack of a specific policy for insulin flexpen use and inconsistent updating of medication instructions contributed to the deficiencies.