Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy and regulation. During medication administration observations, three errors were identified out of 29 opportunities, resulting in a 10.34 percent error rate. The errors included improper handling and administration of medications by nursing staff. Specifically, one nurse crushed an extended-release tablet of Metoprolol Succinate before administering it to a resident with hypertension, despite manufacturer instructions and facility policy prohibiting this practice. Another nurse opened a Tamsulosin HCL capsule and administered its contents in applesauce to a resident with obstructive uropathy and benign prostatic hyperplasia, contrary to manufacturer instructions that the capsule should not be opened, crushed, or chewed. A third nurse administered an incorrect dose of aspirin (81 mg instead of the ordered 325 mg) to a resident with heart disease and a right artificial hip joint, who was prescribed aspirin for blood clot prevention. Interviews with the involved nurses confirmed their actions and lack of awareness regarding proper medication administration procedures. The Nursing Home Administrator also confirmed that the medications were not administered as ordered or according to manufacturer instructions. These actions directly led to the facility exceeding the acceptable medication error rate and not adhering to established medication administration protocols.