Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 6.67% error rate during observed medication administration. During a medication pass, a registered nurse administered four medications to a resident and made two errors: the nurse did not prime the resident's Humalog KwikPen before administering insulin, and administered only 500 mg of Omega-3 fish oil instead of the ordered 1000 mg. These errors were confirmed by both observation and subsequent interview with the nurse involved. The resident affected had diagnoses including type two diabetes, weakness, and anemia, and was noted to have severe cognitive impairment. Physician orders specified the correct dosages and administration techniques for both the insulin and fish oil. Facility policy required medications to be administered safely and in accordance with residents' needs, but these protocols were not followed during the observed medication pass.