Medication Error Rate Exceeds 5% Due to Improper Administration and Order Discrepancies
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with three medication errors identified out of 25 observed opportunities, resulting in an 8% error rate. During a medication pass, a nurse administered 11 medications to a resident, including a chewable aspirin tablet and a hydrocodone-acetaminophen tablet. The resident swallowed the chewable aspirin whole instead of chewing it as ordered, and the nurse confirmed this deviation from the prescribed method. The nurse acknowledged that not chewing the medication could alter its effectiveness. Additionally, the hydrocodone-acetaminophen was administered based on outdated pain level parameters, as the medication blister pack and reconciliation count sheet did not match the updated physician order for pain management. The pharmacy had not received the updated order, and the nurse did not clarify the discrepancy with the physician. The resident involved had a history of cerebral infarction and osteomyelitis and was assessed as having moderate cognitive impairment, requiring significant assistance with daily activities. Interviews with nursing staff and the DON confirmed that medications were not administered as ordered and that discrepancies between medication orders and packaging were not addressed. Facility policy required medications to be administered according to prescriber orders, but this was not followed in the observed instances.
Plan Of Correction
F-tag 759 I: Corrective Action for residents found to have been affected: • Resident 1 order for aspirin chewable was clarified with physician by the RN on 5/28/2025. • Resident 1's pain observation/assessment was completed by RN on 5/18/2025. • A 1:1 in-service education was provided by the DON to LVN 4 regarding the Policy and Procedure on administering medication to ensure that residents received their medication per physician orders. II: Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • On 5/28/2025, the Medical Records Director/designee conducted a facility-wide audit of residents on aspirin chewable tablets and hydrocodone-acetaminophen orders to ensure that residents are provided medication per physician orders. • No other residents have been affected by the deficient practice. III: Measures and systemic changes put in place to ensure deficient practices do not recur: • On 05/18/2025, DON/designee conducted an in-service regarding the policy and procedure for administering medication, to licensed nurses. The goal is to ensure proper, timely, and safe administration of medication as prescribed by the physician. • The Pharmacy Nurse consultant will conduct a 3-way medication cart audit on a monthly basis for the presence of medications and accuracy of orders. Findings will be reported to the DON for follow-up. • The Medical Records Director/designee will conduct a daily audit for new physicians' orders for accuracy and will report findings to the DON during the daily stand-up meeting for follow-up. IV: Facility's plan to monitor corrective actions are achieve & sustain compliance; Integrate the POC to QA Process: • DON/designee will report issues or trends per the weekly random audits made on residents on pain management during the monthly QAA meeting x 3 months to ensure compliance. • The Pharmacy consultant will report issues or trends of monthly medication administration given by the pharmacy nurse consultant and monthly in-service educations provided regarding medication administration and review of residents on pain management. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V: Corrective Action Completion Date: 6/12/2025