Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 5 medication errors out of 43 administrations, resulting in an 11.9% error rate. During medication administration observations, one LPN gave a resident an 81 mg chewable Aspirin tablet along with other medications, without ensuring it was chewed as intended. The LPN confirmed that the chewable tablet was not separated and was consumed whole. In another instance, a different LPN administered all medications, including a chewable Phenytoin 150 mg tablet, whole and at the same time, rather than ensuring the chewable tablet was chewed, as confirmed by the LPN. Additionally, the same LPN was observed administering medications to another resident by crushing all ordered medications or opening capsules and mixing them with pudding. The resident's orders included delayed release and extended release medications, which the LPN confirmed were not to be crushed or opened, as this could alter their absorption. Review of the facility's medication administration policy indicated the need to double-check the right medication, dose, route, and time, but the observed practices did not align with these requirements.