Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 23.07%. During medication administration observations, three LVNs were found to have made multiple errors. One LVN cut an unscored vitamin C tablet in half for a resident, contrary to best practices and without a physician's order, resulting in the administration of an inaccurate dose. The same LVN also failed to administer the correct dosages and types of medications to another resident via gastrostomy tube (GT), did not flush the GT between medications, mixed multiple medications together, and did not check for loose stools before administering a stool softener, as required by the physician's order. Another LVN did not follow physician's orders when administering a calcium with vitamin D supplement to a resident, failed to instruct the resident not to chew an extended-release medication, and did not assess for signs of bleeding or bruising prior to administering an anticoagulant. The medication administration record and medication packaging indicated that the extended-release medication should not be chewed or crushed, but the resident was observed breaking the tablet to swallow it more easily, without being advised otherwise by the nurse. A third LVN administered a stool softener to a resident without assessing for loose bowel movements, despite a clear physician's order to hold the medication if the resident had loose stools. In interviews, the LVNs acknowledged the errors and confirmed that they did not follow the required procedures or physician's orders during medication administration. The DON confirmed that nurses are expected to be competent in medication administration and to follow all orders and protocols.