Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
Surveyors identified that the facility failed to administer medications as ordered, resulting in a medication error rate of 12% (3 errors out of 25 opportunities) during observation of medication passes. In one instance, a registered nurse administered only 50 mg of Zinc to a resident, despite the physician's order specifying 110 mg twice daily. The nurse acknowledged the error, noting that the available stock was insufficient and that she sometimes attempted to compensate by giving an additional 50 mg later, but this was not documented and still did not meet the prescribed dose. In another case, an LPN administered three 20 mg capsules of Duloxetine (totaling 60 mg) to a resident instead of the ordered three 30 mg capsules (90 mg). The LPN also failed to provide water and encourage the resident to rinse their mouth after administering a steroid inhaler, contrary to both facility policy and manufacturer guidelines. The medication cart was found to contain both 20 mg and 30 mg Duloxetine capsules, which contributed to the error. The facility's policies require strict adherence to physician orders and proper administration techniques, including mouth rinsing after certain inhalers.