Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and pharmacy instructions for two residents during medication administration, resulting in a medication error rate of 7.69%. In the first instance, a registered nurse administered multiple oral medications, including Carafate, to a resident while the resident was eating breakfast. The pharmacy label for Carafate specified that it should be given at least two hours before or after other medications and on an empty stomach, but the nurse confirmed that it was not administered as directed, and there were no alternative instructions from the physician. In the second instance, another resident received Carbidopa/Levodopa and Acetaminophen mixed in applesauce while eating breakfast. The pharmacy label for Carbidopa/Levodopa instructed that the medication should be placed on the tongue and allowed to disintegrate, but the nurse administered it mixed in applesauce, contrary to the label instructions. The nurse acknowledged this deviation from the pharmacy instructions and stated it was the first time administering the medication in this manner.