Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Practices
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5%, as evidenced by seven medication errors out of 28 observed opportunities, resulting in a 25% error rate for one resident. The errors were identified during a medication administration observation for a resident with diagnoses including hypertension, ventilator dependence, and a gastrostomy tube. The resident required multiple medications to be administered via G-tube, with specific physician orders and parameters for administration, such as holding blood pressure medications if certain vital sign thresholds were not met. During the observed medication pass, a licensed vocational nurse prepared and administered eight scheduled morning medications several hours past the prescribed time without notifying a supervisor or the physician. The nurse did not check the resident's blood pressure or heart rate immediately prior to administering the antihypertensive medication, instead relying on vital signs taken four hours earlier. This was contrary to the physician's order, which required current vital sign assessment before administration. The nurse also failed to inform the nurse practitioner or physician about the delay in medication administration, as required by facility policy. Interviews with facility staff, including the nurse practitioner, registered nurse, director of nursing, and medical director, confirmed that the nurse should have checked the resident's vital signs immediately before administering the blood pressure medication and should have notified the physician about the late administration. Facility policy required medications to be given within one hour of the scheduled time and for staff to notify the physician if this was not possible. The failure to follow these procedures resulted in multiple medication errors for the resident.