Medication Error Rate Exceeds Five Percent Due to Incorrect Administration and Substitution
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during a medication pass, resulting in a ten percent error rate for one resident. Specifically, a registered nurse (RN) did not administer medications as ordered for a male resident with a history of cerebrovascular accident, hemiplegia, muscle weakness, and cognitive confusion. The resident required assistance with activities of daily living and received medications via G-tube. During observation, the RN did not have the prescribed ASA (aspirin) 81 mg capsules available and instead administered a chewable form of ASA through the G-tube. The RN also incorrectly crushed and administered a Calcium D oral tablet that was not intended to be crushed, and substituted Geritol for the prescribed Maalox suspension. These actions were not in accordance with the physician's orders or facility policy, which requires medications to be administered as prescribed. Interviews with the RN revealed a lack of adherence to medication administration protocols, including failure to notify the DON when medications were unavailable and administering substitute medications without physician approval. The RN acknowledged being busy and running behind, which contributed to the errors. The resident was able to respond to some questions and indicated feeling safe and cared for at the facility.