Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by regulation, with an observed error rate of 8% during the survey. In one instance, a registered nurse administered 5 units of rapid-acting insulin subcutaneously to a resident without providing a snack or ensuring the insulin was given immediately prior to a meal. The resident's blood sugar was checked, and the insulin was administered at 7:01 AM, but breakfast was not served until after 8:20 AM, contrary to facility policy that rapid-acting insulin should be given immediately before a meal or with food. In another instance, a licensed practical nurse administered polyethylene glycol to a different resident using a container labeled for another resident. The nurse confirmed that the medication was not labeled for the intended recipient and acknowledged the error. These two medication errors were identified among 25 observed medication administrations, affecting two residents.