Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during a medication pass observation, resulting in a calculated error rate of 6.67%. Two residents were directly affected by medication administration errors. For one resident with a history of chronic obstructive pulmonary disease, osteoporosis, pneumonia, and paroxysmal atrial fibrillation, the LPN administered Senna Plus 8.6-50 mg instead of the ordered Sennoside 8.6 mg. The error was confirmed by the LPN during an interview. Another resident, diagnosed with chronic diastolic heart failure, depression, vascular dementia, paroxysmal atrial fibrillation, and hypertension, received Potassium Chloride ER 20 MEQ in crushed form, contrary to the extended-release medication's administration guidelines. The RN confirmed that the Potassium Chloride ER was crushed and administered in applesauce. Facility policy requires staff to verify correct medication, dose, route, and administration method for each resident, which was not followed in these instances.
Plan Of Correction
F759 Facility observed medication administration error rate of 6.75% affecting residents #43 and #15, when LPN administered Senna Plus to resident #43 instead of ordered Senna and RN crushed potassium chloride for resident #15. Step 1: The facility RN #204 immediately notified the PCP with no new orders on 6/4/25. Residents #43 was assessed by the facility DON with no negative findings and resident #15 was assessed by RN #204 without negative effects observed on 6/4/25. The LPN #257 and RN #204 were immediately educated by the facility DON on medication administration principles as well as medication error prevention. Completed on 6/5/25. Step 2: All residents have the potential to be affected by medication error rate of 6.75%. Step 3: To prevent this from recurring the DON or designee will educate licensed nursing personnel on principles of proper medication administration, including medications that can/cannot be crushed and medication error prevention as well as having updated medication administration competencies. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will complete medication administration audits 2x per week x4 weeks then 2x per month x2 months. Audits will begin on 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. F760 Facility failed to prevent significant medication administration error for resident #15, when RN #204 crushed potassium chloride for resident #15. Step 1: The facility RN #204 immediately notified the PCP; no new orders. The RN #204 assessed resident #15 without negative effects observed. The RN #204 was immediately educated by the DON on medication administration principles as well as medication error prevention with special focus on medications that cannot be crushed. Completed on 6/5/25. Step 2: This has the potential to affect residents that require medications being crushed. The DON will review medication lists for residents that require mechanically altered medications on 7/10/25. Step 3: To prevent this from recurring the DON or designee will educate licensed nursing personnel on principles of proper medication administration and medication error prevention with special focus on medications that cannot be crushed. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will complete medication administration audits 2x per week x4 weeks then 2x per month x2 months. Audits will begin on 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.