Medication Error Rate Exceeds Regulatory Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by regulation and its own policies. During medication administration observations, eight errors were identified out of 30 opportunities, resulting in a 26.67% error rate. Three licensed nurses were involved in these errors, which affected one sampled resident and two non-sampled residents. The errors included improper administration of medications via gastrostomy tube (GT), failure to administer prescribed medications, and administration of medications not ordered by the physician. One nurse did not follow physician orders for a resident receiving medications via GT. The nurse failed to dilute potassium chloride as ordered, did not administer medications separately, and did not flush the GT between medications, contrary to both physician orders and facility policy. Medication residue was observed in cups, and the nurse confirmed the medications were not supposed to be combined. The nurse also acknowledged not diluting the potassium chloride as required, despite the physician's explicit instructions. Another nurse administered a different brand of artificial tears than what was ordered for a resident, without verifying if the ingredients matched the prescribed medication. A third nurse administered calcium without vitamin D to a resident, despite the physician's order specifying a combination of calcium with vitamin D. The nurse confirmed the correct medication was not available in the cart at the time and acknowledged administering a medication not ordered by the physician. Facility leadership was informed of these findings and acknowledged the deficiencies.