Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in two medication errors out of 29 observed opportunities, for a total error rate of 6.9%. In one instance, a registered nurse prepared to administer 21 units of Humalog insulin to a resident using a Kwikpen device that was labeled for a different resident and had already been opened. The nurse also failed to prime the needle with two units of insulin before programming the dose, contrary to manufacturer instructions and facility policy. The surveyor intervened before the injection was given, and the nurse confirmed the errors during an interview. In another case, a licensed practical nurse administered only one tablet of cholecalciferol (vitamin D3) 1000 units to a resident, despite an active order for two tablets totaling 2000 units daily. The nurse confirmed during an interview that only one tablet was given, not the prescribed dose. These two incidents contributed to the facility's medication error rate exceeding the acceptable threshold.