Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 9%, which exceeds the acceptable threshold of 5%. During medication administration observations, three errors were identified out of 32 opportunities. These errors involved three residents and included improper administration techniques, failure to follow manufacturer instructions, and inaccurate documentation in the Medication Administration Record (MAR). One resident received ophthalmic medication, but immediately after administration, used a tissue to squeeze and wipe the eyes, contrary to standard practice. The staff member present acknowledged that the resident should not have wiped the eye drops from the eyes in this manner. Another resident was administered Linzess, a medication intended to be given on an empty stomach, after breakfast. The nurse administering the medication was unaware of the specific administration requirements, and the MAR did not include instructions to give the medication before meals or on an empty stomach. A third resident had a blood pressure medication, metoprolol, held due to low systolic blood pressure as per physician orders. However, the MAR was inaccurately documented, indicating the medication was given when it was actually held. The nurse confirmed that there was no documentation to reflect that the medication was withheld, and the Director of Nursing agreed that the documentation should have accurately indicated when a medication was held. Facility policies reviewed required proper administration techniques, adherence to manufacturer instructions, and accurate documentation when medications are held.