Medication Administration Errors and Failure to Follow Manufacturer Instructions
Penalty
Summary
The facility failed to ensure that medications were administered according to manufacturer instructions and accepted clinical standards during medication administration observations. In one instance, a licensed nurse prepared MiraLAX for a resident by mixing it in approximately 8 ounces of fluid, but the resident only consumed half of the solution and left the remainder on the bedside table. The nurse did not prompt the resident to finish the dose or remove the medication before leaving the room. Manufacturer directions for MiraLAX require the full contents to be ingested immediately after mixing, and facility policy prohibits leaving prepared medications unattended at the bedside without a licensed practitioner's order. In another instance, a licensed nurse administered Lovenox subcutaneously to a resident in the right lower abdomen, the same site used for the previous day's dose, without verifying prior injection sites. The nurse stated she relied on the resident's preference for injection location. The manufacturer's instructions for Lovenox specify that injection sites should be rotated among different areas of the abdomen to prevent local irritation or tissue damage. These observed failures resulted in a medication error rate of 9.7%, exceeding the acceptable threshold.