Medication Error Rate Exceeds Regulatory Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 26 opportunities, resulting in an 11.54% error rate. For one resident with renal insufficiency, dyspnea, and vascular dementia, a nurse allowed the resident to self-administer a corticosteroid inhaler and artificial tears without proper assessment for self-administration capability. The resident was not instructed to rinse her mouth after using the inhaler, as required by the physician's order and manufacturer’s instructions, and improperly administered the eye drops by dragging the bottle tip across her eyelashes and using more than the prescribed number of drops. The nurse acknowledged these errors during an interview, noting nervousness as a factor for not providing proper instruction. In another instance, a nurse administered Lispro insulin via a prefilled pen to a resident with diabetes mellitus without priming the pen as required by the manufacturer’s instructions and facility policy. The nurse was unaware that priming was necessary each time, not just with new pens. Both the DON and Pharmacy Consultant confirmed that priming is a required step to ensure correct dosing. These actions contributed to the facility’s medication error rate exceeding the regulatory threshold.