Medication Administration Errors and Lack of Resident Education
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 22.58%. During medication administration, two licensed nurses were found to have made multiple errors. One nurse administered medications to a resident that did not match the physician's orders, including giving a tablet form of a multivitamin instead of the prescribed packet form due to a supply shortage, and provided the incorrect dosage of calcium. The nurse confirmed these errors during an interview and acknowledged that clarification with the physician should have occurred at the time of admission. Another nurse failed to provide necessary education to two residents regarding the proper administration of extended-release (ER) medications, specifically not instructing them not to chew the ER tablets. One resident was observed making chewing motions while taking ER nifedipine and potassium chloride, and the nurse did not intervene or provide guidance. Additionally, the same nurse did not assess or inquire about signs or symptoms of bleeding or bruising before administering apixaban, an anticoagulant, to both residents, despite physician orders requiring such monitoring. Interviews with staff confirmed the medication errors and lapses in protocol. The central supply process for reordering medications was described, and it was noted that nurses would request needed over-the-counter medications, with the central supply staff responsible for obtaining them. The errors were verified by nursing and administrative staff, who acknowledged that proper procedures were not followed in these instances.