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 three medication errors observed out of twenty-eight opportunities during a medication pass, resulting in a 10% error rate. Specifically, a Licensed Vocational Nurse (LVN) administered two types of insulin to a resident with dysphagia and muscle weakness but did not follow the manufacturer's instructions for holding the insulin pen needle in the skin for the required duration after pressing the dose button. The LVN admitted to routinely removing the pen immediately after pressing the button, rather than adhering to the specified holding time. Additionally, the same LVN administered a nasal spray to the same resident without instructing the resident to blow their nose beforehand, contrary to standard manufacturer instructions for intranasal sprays. The LVN stated that she was unaware of the need for the resident to clear their nasal passages prior to administration. These observed actions contributed to the facility's medication error rate exceeding the acceptable threshold.