Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by five medication errors out of 26 observed opportunities, resulting in a 19.23% error rate. One resident with diagnoses including COPD, asthma, and orthostatic hypotension did not receive Budesonide and Midodrine as ordered during the morning medication pass. The nurse responsible stated she forgot the respiratory medications and later discovered Budesonide was not available in the medication cart. The nurse also did not administer Midodrine due to its absence from the cart and did not follow the facility's protocol to check the emergency supply or contact the pharmacy for a stat delivery. Additionally, the same resident did not receive Ipratropium nasal spray at the correct time and the administration did not follow manufacturer instructions, such as priming the spray, instructing the resident to blow their nose, or using the correct head positioning. Trelegy, another respiratory medication, was also administered outside the prescribed time frame. The nurse admitted to being unsure of the correct administration technique for the nasal spray and confirmed that medications should be given within one hour of the scheduled time, as per facility policy. Another resident with dysphagia received Midodrine via G-Tube, but the nurse failed to flush the tube with water after administration, contrary to facility policy. The nurse acknowledged that an additional flush was necessary to ensure the medication cleared the tubing and to prevent clogs. These observed failures were confirmed through interviews, record reviews, and direct observation, and were not in accordance with the facility's medication administration policies and procedures.