Medication Error Rate Exceeds 5% Due to Insulin, Antidepressant, and Opioid Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during medication administration observations, as evidenced by errors involving two residents. For one resident, a registered nurse administered Lantus insulin from a pen that had been opened 38 days prior, exceeding the manufacturer’s guideline to discard after 28 days from opening. The nurse stated she followed the manufacturer’s expiration date rather than the open date, and the unit manager confirmed that while facility policy required discarding insulin pens 30 days after opening, this was not included in orientation education and was expected knowledge from nursing school. Another resident did not receive a scheduled dose of Wellbutrin 150 mg because the nurse reported the medication was not available and did not check the medication cart’s bottom drawer, where extra medications were stored. The medication administration record showed inconsistent documentation, with the medication marked as given on days when it may not have been administered. Additionally, the same resident was given Oxycodone 5 mg instead of the scheduled Morphine Sulfate ER, and the nurse documented that Morphine had been administered. The nurse later acknowledged the error and indicated she would correct the documentation. Facility policies required medications to be stored according to manufacturer recommendations and for staff to verify medication details, including expiration dates, prior to administration. Observations and interviews revealed lapses in following these policies, including inadequate checks for medication availability and improper administration and documentation of medications. These actions resulted in a medication error rate above the acceptable threshold.