High Medication Error Rate Due to Improper Administration and Omission
Penalty
Summary
The facility was found to have a medication error rate of 25.93%, with 7 errors out of 27 observed opportunities during medication administration for four residents. Specific incidents included a nurse failing to administer gabapentin and tamsulosin as ordered due to lack of medication on hand, and crushing and administering levetiracetam and Klor-Con ER tablets to a resident despite clear labeling that these medications should not be crushed. The nurse confirmed these actions during interviews, and review of facility policy indicated that long-acting or extended-release medications should not be crushed and alternatives should be sought. Additional errors included a nurse administering a lower dose of calcium carbonate (500 mg) than ordered (1250 mg) via a nasogastric tube to a resident, and another nurse administering a multivitamin tablet without the required folic acid ingredient to a resident as per physician order. There was also an instance where a nurse failed to instruct a resident to shake a Symbicort inhaler and rinse their mouth after use, contrary to the medication label instructions. These actions were confirmed through observation, interviews with the nursing staff, and review of physician orders and facility policies.