Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to ensure proper medication administration for three out of twenty-eight observed opportunities, resulting in an 11% medication error rate. During medication passes, a respiratory therapist did not instruct a resident to exhale fully or hold their breath as required when administering Combivent Respimat and Ellipta inhalers. The manufacturer's instructions for both inhalers specify that the patient should exhale fully before inhalation and hold their breath after inhaling the medication, but these steps were omitted during administration. The respiratory therapist acknowledged forgetting to provide these instructions during the observed medication passes. Additionally, a licensed vocational nurse administered Humalog insulin to another resident in the same abdominal site as the previous injection, contrary to the manufacturer's instructions to rotate injection sites to reduce the risk of lipodystrophy. Review of the medication administration record confirmed repeated use of the same injection site. The nurse admitted to forgetting to rotate the site during the observed administration.