Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to administer medications as ordered and in accordance with manufacturer guidance, resulting in a medication error rate of 12.9% (four errors out of 31 opportunities). For one resident, a physician order required Clopidogrel bisulfate 75 mg to be given once daily in the morning, and a separate order specified a multivitamin without minerals. On the day of observation, the LPN preparing medications reported that Clopidogrel was unavailable and instead prepared and administered a multivitamin with minerals, contrary to the physician's order. This resulted in two medication errors for this resident. For another resident, physician orders included a daily multivitamin and insulin Lispro with specific dosing instructions based on blood glucose levels. The RN prepared and administered a multivitamin with minerals instead of the ordered multivitamin, and administered 24 units of insulin Lispro using a Kwik-pen that did not have an open date recorded, despite manufacturer instructions that the pen should not be used more than 28 days after opening. The RN was made aware of the missing open date but proceeded with administration, resulting in two additional medication errors. The facility's policy required verification of the right drug, dose, route, rate, time, and resident prior to administration, which was not followed in these instances.